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MEDICAL  DIAGNOSIS 


A  MANUAL  OF  CLINICAL  METHODS 


BY 

J.  GRAHAM  BEOWN,  M.D. 

FELLOW    OP   THE    ROYAL   COLLEGE    OF    PHYSICIANS    OF    EDINBURGH  ;     LATE    SENIOR 
PRESIDENT  OF  THE    ROYAL  MEDICAL  SOCIETY  OF  EDINBURGH 


SECOND  EDITION,  ILLUSIBATED 


"Felix,  qui  potuit  rerum  cognoscere  caiasas."— Vibg.,  Georg. U.  490 


BERMINGHAM  &  COMPANY 


28  Union  Square,  East 
New  York 


20  King  William  St.  ,  Strand 
London 


1884 


PREFACE. 


It  is  a  creditable  characteristic  of  the  treatment  of  dis- 
ease in  the  present  day  that  it  seeks  to  proceed  on  rational 
principles.  Some  there  may  still  be  who  think  it  enough 
to  give  a  name  to  a  collective  group  of  symptoms,  and 
treat  the  disease  as  they  have  Ijeen  told  an  affection  bear- 
ing that  name  should  be  treated.  There  may  be  others 
who  seize  upon  a  few  prominent  symptoms,  and  direct 
their  remedies  exclusively  to  these.  But  every  day  is, 
happily,  reducing  the  number  of  these  routine  practitioners, 
and  teaching  that  the  true  physician  is  he  who  seeks  thor- 
oughly to  investigate  the  phenomena  of  the  disease,  that  in 
this  way  he  may  the  better  arrive  at  a  knowledge  of  that 
from  which  they  proceed,  and  to  which,  therefore,  his  treat- 
ment should  be  directed.  But  this  can  only  be  arrived  at 
by  a  thorough  knowledge  of  every  change  which  disease 
produces  in  the  body,  and  by  a  clear  conception  of  what 
that  change  imports.  This  constitutes  the  science  of  Diag- 
nosis, and,  without  accurate  diagnosis,  there  can  be  no  ra- 
tional treatment. 

The  signs  and  symptoms  of  disease  are  changes  produced 
in  the  animal  economy,  which  are  cognoscible  by  our 
senses — some  by  one,  others  by  another  ;  while  to  assist 
these  senses  we  call  in  the  aid  of  instruments  which  extend 
their  range  or  increase  their  power,  and  of  the  various  ana- 
lytical processes  which  the  science  of  Chemistry  places  at 
our  disposal. 

In  the  following  pages  an  attempt  has  been  made  to  de- 
scribe these  signs  and  symptoms  of  disease,  and  to  show 
what  is  their  value  from  a  diagnostic  point  of  view.  If  this 
attempt  be  at  all  successful,  it  may  enable  the  student  of 
disease  to  save  much  valuable  time,  by  assisting  him  in 
analyzing  and  weighing  the  evidences  of  disease,  and  ex- 
tracting from  the  whole  phenomena  which  are  presented  to 


4  PREFACE. 

him  those  which  are  of  value  as  indicating  its  nature.  The 
attempt  is  made  not  with  a  view  of  checking  but  rather  of 
encouraging  minute  inquiry,  while  it  aims  at  giving  to  the 
result  of  that  inquiry  more  definite  form. 

A  man  who  has  clearly  grasped  a  case  in  its  entirety, 
who  has  separated  the  essential  from  the  accidental,  and 
who  has  ascertained  the  weight  and  bearing  of  each  indi- 
vidual symptom,  can  go  steadily  forward  in  the  treatment 
of  his  case  without  experiencing  that  harassing  doubt 
which  arises  from  partial  or  crude  observation,  and  which, 
to  a  conscientious  mind,  cannot  but  prove  a  severe  trial. 

I  desire  to  express  my  thanks  to  my  friends  who  have 
encouraged  and  aided  me  in  carrying  out  my  design; 
among  others,  to  Professor  Grainger  Stewart,  from  whom 
I  have  uniformly  received  much  kind  sympathy  and  advice. 
To  Professor  C.  S.  Roy  I  am  indebted  not  only  for  the  heart 
and  pulse  tracings  with  which  I  have  illustrated  Chapter 
XIII.,  but  for  very  valuable  assistance  which  I  have  received 
at  his  hands.  Dr.  Alexander  R.  Coldstream,  of  Edinburgh, 
has  materially  assisted  me  in  the  correction  of  the  proof- 
sheets.  J.  G.  B. 
63  Castle  Street, 
Edinburgh,  15^^  September,  1882. 


TABLE   OF   CONTENTS. 


FAGS 

Introduction 13 

Chap.  i.     The  General  Aspect,    Condition,    and    Circum- 
stances  of  a  Patient 15 

Family  History 16 

Habits  and  General  Surroundings 16 

Previous  General  Health 16 

Origin  and  Course  of  Illness 16 

Present  Condition  of  the  Patient 17 

Height  and  Weight 17 

Development  and  Muscularity 17 

Changes  in  the  Color  of  the  Skin 18 

Pallor 18 

Redness l8 

Cyanosis 18 

Jaundice 18 

Bronzing 19 

Grayness 20 

CEdema  of  the  Skin 20 

Emphysema  of  the  Skin 20 

Perspiration 20 

Expression  of  the  Face 21 

Temperament,  Constitution,  or  Diathesis. . .  21 

Sanguine  Constitution 22 

Nervous             "            22 

Strumous           **           22 

Lymphatic         "           22 

Bilious               "           22 

Gouty                "           22 

Rheumatic         "           22 

Attitude  of  the  Patient • . .  23 

Evidence  of  Previous  Disease 23 

Temperature 23 

Chap,  ii.     Alimentary  System 25 

Condition  of  the  Lips 26 

Color 26 

Form 26 


6  TABLE   OF  CONTENTS. 

Chap.  ii. — Continued.  page 

Movements 27 

Condition  of  the  Teeth 28 

Condition  of  the  Gums  and  Mucous  Mem- 
brane of  the  Cheeks 28 

Condition  of  the  Tongue 28 

Form  of  the  Tongue 28 

Movements 29 

Surface 29 

Fur  on  the  Tongue 30 

Saliva 31 

Fauces 32 

Mastication 33 

Deglutition 34 

Examination  of  the  CEsophagus 34 

Appetite 36 

Thirst 36 

Sensations  during  fasting 36 

Sensations  after  eating 36 

Acidity 37 

Flatulence 38 

Nausea  and  Vomiting 38 

Examination  of  vomited  Matter 39 

Defaecation 1. 40 

Character  of  the  Faeces 41 

Chap.  hi.     Examination  of  the  Abdomen 42 

Inspection  of  the  Abdomen 42 

General  Prominence 43 

Retraction 44 

Local  Tumefaction 44 

Abdominal  Movements 45 

Chap.  IV. Palpation  of  the  Abdomen 46 

Condition  of  the  Abdominal  Walls 47 

Condition  of  the  Peritoneal  Cavity 47 

Condition  of  the  Liver. .  *. 48 

Surface 48 

Tenderness 48 

Consistence 48 

Size 49 

Shape 49 

Condition  of  the  Spleen 49 

"             "       Pancreas 50 

"             "       Stomach  and  Intestines... .  50 

"             "       Mesenteric  Glands 51 

**             "       Kidneys 52 

"             "       Urinary  Bladder 52 

"             "       Abdominal  Aorta 52 

Chap.  v. Percussion  of  the  Abdomen 53 

Peritoneal  Cavity 53 

Liver 54 

Spleen 57 

Kidneys.. 58 

Stomach 59 

Auscultation  of  the  Abdominal  Organs 60 


TABLE   OF   CONTEN  rs.  7 

PACK 

Chap.  vi.     Haemopoietic  System 60 

Lymphatic  Vessels 61 

Inflammation 61 

Narrowing  and  Dilatation 61 

Rupture 62 

Lymphatic  Glands 62 

Ductless  Glands 63 

Examination  of  the  Blood 64 

Microscopic  Examination 64 

Enumeration  of  the  Blood-corpuscles 66 

Estimation  of  Haemoglobin 68 

Chap.  vh.     Circulatory  System 69 

Subjective  Phenomena 69 

Pain 70 

Palpitation 70 

Fainting 70 

Chap.  viii. Inspection 71 

Cardiac  Impulse 71 

Pulsation  at  the  root  of  the  Neck 72 

Epigastric  Pulsation 74 

Arterial  Pulsation  on  Thoracic  Wall 75 

Chap.  ix. Palpation 76 

Cardiac  Impulse 76 

Alterations  in  Position 76 

"      Strength 77 

•'       Extent 78 

Double  Apex-beat 78 

Endocardial  Thrills 78 

Pericardial  Friction   79 

Chap.  x. Percussion 79 

Position  of  the  Heart 79 

Absolute  Cardiac  Dulness 81 

Relative  Cardiac  Dulness 81 

Aortic  Dulness 81 

Chap.  xi. Auscultation 83 

Heart  Sounds  in  Health 84 

Areas  for  Auscultation 84 

Modifications  of  the  Normal  Sounds  of  the 

Heart 85 

Variations  in  Intensity 85 

Impurity  of  the  Sounds 86 

Reduplication  of  the  Sounds 86 

Murmurs 87 

Endocardial  Murmurs 87 

Method  of  production  of  Murmurs.  88 

Rhythm 89 

Intensity  and  Propagation 89 

Condition  of  the  Normal  Sound  at 
the  Orifice  at  which  the  Mur- 
mur originates 90 

Mitral  Murmurs 9^ 

Tricuspid  Murmurs 92 

Aortic  Murmurs. 93 


8  TABLE  OF  CONTENTS. 

Chap.  XI. — Continued.  page 

Pulmonary  Murmurs 93 

Murmurs  of  Non- Valvular  Origin.,  94 

Exocardial  Murmurs 94 

Pericardial  Friction 94 

Chap.  XII. Examination  of  the  Arteries 95 

Inspection 95 

Palpation 95 

Radial  Pulse 95 

Frequency 95 

Rhythm 96 

Character 97 

Expansion 97 

Tension 97 

Volume 98 

Percussion 98 

Auscultation 98 

In  Health 98 

In  Disease 99 

Cephalic  Murmurs 99 

Examination  of  the  Capillaries 100 

Examination  of  the  Veins 100 

Inspection loo 

Auscultation lOO 

Bruit  de  Diable loi 

Graphic  Clinical  Methods 103 

Sphygmograph 104 

Typical  Healthy  Curve 114 

Anacrotic  Pulse  Curve 114 

Dicrotic  Pulse  Curve 114 

Hyperdicrotic  Pulse  Curve 115 

Cardiograph 115 

Sphygmomanometer 117 

Note  on  the  Measurement  of  Tracings..  117 

Chap.  XIII.     Respiratory  System 119 

Subjective  Phenomena 119 

Cough 120 

Sputa 121 

Chemical  Characters 122 

Macroscopic  Characters 122 

Physical  Characters 123 

Microscopic  Characters 124 

Chap.  XIV. Examination  of  Nares 128 

Examination  of  the  Larynx 129 

Voice 129 

Palpation  of  the  Larynx 130 

Laryngoscopic  Examination 130 

Chap.  XV. Inspection  of  the  Thorax I35 

Regions  of  the  Thorax 135 

Form  of  the  Thorax 136 

Respiratory  Movements 138 

Frequency 139 

Rhythm I39 

Cheyne-Stokes  Respiration, . ......  139 


TABLE  OF  CONTENTS.  9 

Chap.  XV. — Continued.  pack 

Type 140 

Pain  and  Difficulty  in  Breathing 140 

Dyspnoea 140 

Extent  of  Respiratory  Movements 141 

Chap.  xvi. Palpation  of  the  Thorax 141 

Vocal  Fremitus 142 

Pleural,  Bronchial,  and  Cavernous  Thrills. .  143 

Fluctuation 143 

Chap.  xvii. Mensuration 143 

Tape  Measure 143 

Callipers 144 

Cyrtometer 144 

Thoracometer 145 

Stethograph 145 

Spirometer 145 

Pneumatometer 145 

Theory  of  Percussion   146 

Chap,  xviii. Percussion  of  the  Chest 147 

Methods  of  Percussion 152 

Percussion  Note  of  the  Chest 152 

The  Intensity  of  the  Percussion  Sound 153 

The  Pitch  of  the  Percussion  Sound. ...    ...  155 

The  Tympanitic  Percussion  Note 156 

Cracked-Pot  Sound 159 

Amphoric  Resonance 160 

The  Feeling  of  Resistance  during  Percussion  160 

Topographical  Percussion 161 

Regional  Percussion 162 

Chap.  XIX. Auscultation  of  the  Lungs 163 

Vesicular  Breathing 164 

Harsh  Breathing , 165 

Jerky  Breathing 165 

Vesicular  Breathing  with  Prolonged  Ex- 
piration    165 

Systolic  Vesicular  Breathing 166 

Bronchial  Breathing 166 

Amphoric  Breathing 168 

Broncho-Vesicular  Breathing 169 

Chap.  XX. Adventitious  Sounds  accompanying  Respira- 
tion    170 

Moist  Rales 170 

Crepitant  Rale 170 

Fine  and  Course  Bubbling  Rales.. .  171 

Dry  Rales 173 

Sonorous  and  Sibilant  Rales 173 

Pleuritic  Friction 173 

Auscultation  of  the  Voice  (Vocal  Fremitus).  174 

Succussion 176 

Chap.  xxi.    Integumentary  System 176 

Subjective  Symptoms I77 

Eruptions 177 

Distribution  and  Configuration 178 

Elements  of  Skin  Involved 17^ 


lO  TABLE   OF   CONTENTS. 

Chap.  xxi. — Continued.  page 

Type  of  the  Eruption 178 

Etiology  of  the  Eruption 181 

Vegetable  Parasites 182 

Achorion  Schonleinii 182 

Trichophyton 183 

Microsporon  Furfur 185 

Animal  Parasites 186 

Sarcoptes  Scabiei 186 

Pediculus 187 

Pulex  Irritans 187 

Demodex  Folliculorum 187 

Chap.  XXII.     Urinary  System 188 

Subjective  Symptoms 188 

Examination  of  the  Urine 189 

Quantity 189 

Color 190 

Transparency 192 

Odor 192 

•            Specific  Gravity 192 

■'                              Reaction 194 

Chap.  XXIII.  — —    Normal  Constituents  of  Urine 195 

Urea 195 

Estimation  by  means  of  Nitrate  of  Mer- 
cury    196 

Estimation  by   means  of  Hypobromite 

of  Soda 197 

Uric  Acid 199 

Creatinin 200 

Indican 201 

Cholorides 202 

Sulphates 203 

Phosphates 204 

Chap.  XXIV. Abnormal  Constituents  of  Urine 206 

Albumen 206 

Paraglobulin 209 

Propeton 209 

Fibrin 210 

Pepton 211 

Mucus 212 

Sugar 212 

Blood 217 

Bile  Pigment 218 

Bile  Acids 218 

Chap.  XXV. Urinary  Sediments , 219 

Blood  Corpuscles 219 

Pus  Corpuscles 219 

Epithelium  > 220 

Renal  Tube-casts 220 

Spermatozoa 221 

Micro-Organisms 221 

Inorganic  Sediments  of  Acid  Urine 225 

Alkaline  Urine 225 

Chap.  xxvi.     Reproductive  System 226 


TABLE   OF   CONTENTS.  II 


PAGE 


Chap.  XXVI. — Cofttinued. 

The  Female  Reproductive  Organs  and  Functions  226 

Menstruation 227 

Amenorrhoea 227 

Menorrhagia 227 

Dysmenorrhoea 228 

Leucorrhoea 228 

Pareunia 228 

Pregnancy 228 

Physical  Examination  of  Female  Organs. . .  228 

Mammae 228 

Abdomen 229 

External  Pudenation 230 

Vaginal  Examination 232 

Bimanual  Examination 232 

Speculum 233 

Uterine  Sound 233 

Instruments  for  dilating  the  Cervix 233 

Chap,  xxvii.     Nervous  System 233 

Sensory  Functions 234 

Subjective  Sensations 234 

Pain 234 

Paraesthesia 235 

Giddiness 235 

Abnormal  Visceral  Sensations 236 

Cutaneous  Sensibility , 236 

Common  Sensibility 236 

Tactile  Sensibility 236 

Sense  of  Pressure 237 

Sense  of  Temperature 237 

^                          Sense  of  Locality 237 

Muscular  Sense 238 

Special  Senses 238 

Sight 238 

Diminution  of  Visual  Acuteness...  239 

Alterations  of  Visual  Field 239 

Alterations    in   the    Perception    of 

Colors 240 

Movements  of  the  Eyeball 240 

Paralysis  of  Ocular  Nerves. . . .  240 

Spasm  of  Ocular  Nerves 241 

Changes  in  the  Pupil 242 

Ophthalmoscopic  Examination 243 

Hearing 244 

Taste 245 

Smell 246 

Chap,  xxviii. Motor  Functions 247 

Visceral  Motor  Functions 248 

Voluntary  Motor  Functions 248 

Voluntary  Movements 248 

Paralysis   248 

Electrical  Reactions 249 

Spasm 250 

Reflex  Movements 251 


12  TABLE  OF  CONTENTS. 

Chap,  xxviii. — Continued.  p^gg 

Superficial  Reflexes 252 

Deep  Reflexes 252 

Affections  of  Co-ordination 253 

Labyrintliine  Vertigo 253 

Ataxia 253 

Cerebellar  Inco-ordination 254 

Vaso-motor  Functions , 254 

Cutaneous  Vaso-motor  Affections 254 

Visceral  Vaso-motor  Affections 255 

Chap.  XXIX. Trophic  Functions 255 

Trophic  Affections  of  Muscles 255 

"                "          Bones  and  Joints..'  255 

Skin 256 

**                "          Secretory  Glands.,  256 

"                 "          Viscera 256 

Chap.  XXX. Cerebral  and  Mental  Functions 256 

Coma 257 

Illusions 257 

Hallucinations 257 

Delusions 257 

Delirium 257 

Speech 258 

Sleep 259 

Chap.  xxxi. Condition  of  Cranium  and  Spine 260 

Chap,  xxxii.     Locomotory  System 260 

Condition  of  Bones 261 

Condition  of  Joints 261 

Condition  of  Muscles 261 

Rigidity 261 

Contracture 261 

Flaccidity ?.  ...  261 

Fibrillary  Twitching 261 

Appendix  A. — On  the  Examination  of  the  Faeces  262 
Appendix  B. — Method  of  Preparing  the  Solution 

of  Nitrate  of  Mercury  used  for  estimating  Urea  263 

Index 265 


MEDICAL    DIAGNOSIS. 


INTRODUCTION. 


A  PHYSICIAN,  when  consulted  by  a  patient,  is  naturally 
enough  expected  to  be  an  attentive  listener  to  what,  to  his 
informed  mind,  is  a  strange  medley  and  most  confused  ac- 
count of  those  deviations  from  health  or  actual  sufferings 
by  which  the  patient  has  been  driven  to  seek  aid.  The 
more  serious  symptoms  are  often  lightly  touched  upon, 
the  more  trivial  exaggerated,  and  the  whole  jumbled  to- 
gether without  logical  sequence  or  the  slightest  attempt  at 
orderly  arrangement.  This  story,  trying  as  it  is  to  the  phy- 
sician, and  all  the  more  trying  the  more  his  own  mind  is 
duly  trained,  he  ought  to  listen  to;  for  this  the  patient  ex- 
pects, and  perhaps  has  a  right  to  expect.  During  the  te- 
dious narration  it  may  give  him  patience  to  bear  in  mind 
two  considerations:  first,  that  from  it  he  must  obtain  the 
right  end  of  the  clue  which  is  to  guide  him  in  the  difficult 
task  of  ascertaining  the  nature,  extent,  and  seat  of  the  dis- 
ease; and  second,  that  by  this  often  most  prolix  narrative, 
taken  along  with  his  attitude,  manner,  and  expression,  the 
patient,  absorbed  in  his  own  sufferings,  is  giving  his  phy- 
sician, if  he  is  careful  and  observant,  the  best  opportunity 
of  becoming  acquainted  with  the  ego  with  whom  he  has  to 
deal. 

The  most  critical  examination  of  symptoms,  the  most 
careful  inquiry  into  the  state  of  internal  organs,  the  most 
logical  deductions  from  these  as  to  the  morbid  changes  from 
which  they  have  originated,  will  often  be  erroneous  unless 
the  physician  is  also  a  student  of  human  nature,  and  is  able 
to  arrive  almost  intuitively  at  some  knowledge  of  the  men- 
tal characteristics  and  peculiarities  of  his  patient. 

But  sooner  or  later,  and  more  often  later  than  sooner, 


14  INTRODUCTION. 

the  patient  will  have  arrived  at  the  end  of  his  narration, 
and  then  the  physician  must  unravel  for  himself  this  tan- 
gled web;  and,  taking  the  different  threads,  he  must  follow 
them  up,  and  by  means  of  close  physical  examination  as- 
certain the  condition  of  the  various  organs  of  the  body — 
particularly  those  which  the  train  of  symptoms  detailed  in- 
dicate to  be  implicated  in  the  morbid  process.  It  is  only 
by  a  methodical  examination  of  the  different  systems  of  the 
body  that  a  satisfactory  view  of  the  condition  of  the  patient 
can  be  obtained,  and  the  very  foundation  of  rational  treat- 
ment laid. 

In  the  following  pages  an  attempt  will  be  made  to  explain 
the  meaning  and  diagnostic  significance  of  the  chief  symp- 
toms and  physical  signs  which  are  met  with  in  disease. 
These  group  themselves  naturally  round  the  different  phy- 
siological systems  of  the  body — Alimentary,  Absorbent 
and  Hsemopoietic,  Circulatory,  Respiratory,  Integumentary, 
Urinary,  Reproductive,  Nervous,  Locomotory;  and  under 
these  headings  they  will  be  considered.*  This  is  not,  of 
course,  to  be  looked  upon  as  a  rigidly  accurate  division, 
but  for  practical  purposes  it  suffices,  and  it  has  this  great 
advantage — viz.,  that  those  who  are  habituated  to  follow 
such  an  arrangement  in  the  examination  of  patients  are  less 
apt  to  neglect  minute  points  which  might  otherwise  escape 
the  memory.  Nor  is  it  to  be  supposed  that  every  patient 
requires  to  be  subjected  to  so  exhaustive  a  catechizing  as 
this  arrangement,  if  fully  carried  out,  would  necessitate. 
Many  trivial  complaints  call  for  no  such  exercise  of  patience 
either  on  the  part  of  the  physician  or  on  that  of  his  patient, 
and  in  severe  or  urgent  cases  the  first  examination  must 
necessarily  be  at  best  rapid  and  limited.  Nor  even  where 
close  inquiry  is  desirable  is  it  necessary  to  follow  accurately 
the  sequence  here  given;  and  to  some  it  may  seem  more 
suitable  to  clear  up,  first  of  all,  the  details  regarding  that 
system  which  seems  most  profoundly  implicated,  and  only 
thereafter,  and  more  cursorily,  to  examine  into  the  condi- 
tion of  the  others. 

It  must  be  carefully  borne  in   mind  that   in  examining  a 


*  We  follow  in  this  respect  the  order  of  case-reporting  which  obtains 
in  the  wards  under  the  care  of  the  Professors  of  Clinical  Medicine  in  the 
University  of  Edinburgh;  and  with  this  arrangement  the  author  has  long 
been  familiar,  as  it  closely  corresponds  to  that  which  had  been  drawn  up 
by  Professor  Grainger  Stewart,  and  which  was  in  use  at  the  time  the 
author  was  his  Resident  Physician  in  the  Royal  Infirmary. 


CONDITION  AND   CIRCUMSTANCES   OF  A   PATIENT.    1 5 

pati&nt  we  are  dealing  with  a  fellow-creature,  and  that  all 
our  inquiries  and  all  our  investigations  must  be  conducted 
with  the  utmost  courtesy,  kindness,  and  patience. 

In  the  following  pages  attention  will  first  be  directed  to 
certain  preliminary  inquiries  which  should  be  made,  and 
then  to  the  various  systems,  in  the  order  already  mentioned. 


CHAPTER   I. 


The   General   Aspect,   Condition,   and    Circumstances 

OF  A  Patient. 

Preliminary  Inquiries — Family  History — Habits  and  General  Sur- 
roundings at  Home  and  at  Work — Previous  General  Health — Origin 
and  Course  of  Present  Illness.  Present  Condition — Height  and 
Weight — Development  and  Muscularity — Color  of  the  Skin — Cutaneous 
(Edema  and  Emphysema — Perspiration — Expression  of  Face — Tem- 
perament— Attitude — Obvious  Evidence  of  Previous  Disease  or  In- 
jury— Temperature. 

Before  entering  upon  the  more  minute  examination  of 
a  patient,  there  are  several  more  general  and  preliminary 
inquiries  which  should  be  made,  and  it  is  needless  to  say 
that  the  care  and  extent  of  the  investigation  required  must 
depend  on  two  factors:  first,  on  its  necessity,  in  view  of  the 
special  disease  present;  and  second,  on  the  mental  and 
bodily  condition  of  the  patient. 

After  noting  the  patient's  name,  age,  occupation,  resi- 
dence, etc.,  it  is  well  to  record  in  as  brief  words  as  possible, 
and  in  his  own  language,  his  chief  complaint.  This  is  not 
to  be  in  any  sense  a  statement  of  diagnosis,  but  simply  the 
patient's  own  impression  concerning  his  case.  Both  in 
cases  of  phthisis  and  bronchitis,  for  example,  we  might  be 
told  that  the  patient  sought  advice  on  account  of  severe 
cough,  and  of  this  symptom  we  would  make  note  as  the 
most  prominent  in  his  own  mind.  We  further  ascertain,  as 
closely  as  we  can,  the  duration  of  the  present  illness,  and 
record  it  briefly — so  many  days,  months,  etc.,  as  the  case 
may  be. 

Having  thus  formed  in  our  minds  a  general  idea,  however 
ill-defined,  of  the  case  before  us,  we  proceed  to  consider  the 


l6  MEDICAL  DIAGNOSIS.  , 

Family  History. — Inquiry  into  the  general  health  of  the 
patient's  family  should  be  specially  directed  to  ascertain 
whether  any  of  his  near  relatives  have  suffered  from  those 
forms  of  disease  which  are  usually  supposed  to  be  heredi- 
tary, such  as  consumption,  scrofula,  syphilis,  rheumatism, 
gout,  heart  disease,  and  various  nervous  disorders.  Such 
inquiry  must  not  limit  itself  to  the  near  relatives,  father, 
mother,  brothers,  and  sisters,  but  ought  to  extend  to  the 
aunts,  uncles,  and  grandparents. 

Habits  and  General  Surroundings  at  Home  and  at  Work. 

— Luxurious  habits,  "  fast"  living,  and  excesses  of  all  kinds, 
are  frequently  the  cause  of  disease,  and  any  evidence  of 
these  must  be  sought  for,  and  among  them  excessive  alco- 
holic indulgence  stands  out  prominently.  To  insufficient 
or  unwholesome  diet  many  ailments  may  be  traced,  as  well 
as  to  long  hours  of  work,  and  to  the  bad  ventilation  or  de- 
fective drainage  of  the  apartments  used.  It  is  also  well 
known  that  certain  occupations  have  a  special  tendency  to 
produce  disease,  among  which  may  be  mentioned  the  pul- 
monary affections  met  with  in  miners,  stone-masons,  and 
cutlers,  the  anthrax  which  attacks  wool-sorters,  and  the 
plumbism  from  which  painters  suffer. 

We  next  proceed  to  inquire,  with  some  minuteness,  into 
the 

Previous  General  Health. — Ascertaining  the  usual  state  of 
health,  the  date  and  nature  of  former  ailments,  liability  to 
particular  morbid  conditions,  present  or  previous  residences, 
or  other  circumstances  which  may  have  influenced  its  pro- 
duction or  development,  exposure  to  contagion,  etc.;  and,  if 
the  patient  be  a  female,  it  may  be  advisable  to  inquire  into 
the  condition  of  the  reproductive  functions. 

Origin  and  Course  of  the  Present  Illness. — It  is  impossi- 
ble here  to  do  more  than  indicate  certain  general  lines  on 
which  it  is  usual  to  proceed.  Having  already  fixed  the 
date  of  commencement  of  the  illness,  we  would  next  en- 
deavor to  gain  some  accurate  idea  of  the  manner  in  which 
it  commenced;  with  what  symptoms;  whether  it  came  on 
suddenly  or  gradually;  to  what  cause  the  patient  traces  his 
loss  of  health;  and,  if  his  statement  does  not  appear  proba- 
ble to  us,  we  must  strive,  by  careful,  guarded,  and  unob- 
trusive cross-examination,  to  satisfy  ourselves  on  these 
points.     Knowing  the  usual  etiology  of  such  a  case  as  the 


CONDITION  AND   CIRCUMSTANCES   OF  A  PATIENT.    1/ 

one  we  are  studying,  we  possess  a  guide  as  to  the  direction 
in  which  our  inquiries  should  be  made.  The  sequence  of 
symptoms  may  now  be  ascertained,  the  date  of  origin  of 
each,  and  its  severity;  and,  finally,  we  note  to  what  medical 
treatment  the  patient  has  been  subjected,  and  what  was  its 
result  in  his  case. 


PRESENT   CONDITION. 

Before  proceeding  to  the  examination  of  each  system  of 
the  body;  it  is  advisable  first  to  note  certain 

General  Facts. 

1.  Height  and  Weight. — In  almost  all  diseases  the  weight 
becomes  diminished,  and  in  the  course  of  treatment  the 
patient  should,  when  it  is  practicable,  be  weighed  at  regu- 
lar intervals,  when  a  very  valuable  indication  of  the  progress 
of  the  malady  will  be  in  our  hands.  When,  however,  we 
have  only  the  result  of  one  weighing,  it  is  of  consequence 
to  know  what  a  man  of  a  given  height  ought  to  weigh  when 
in  health.  For  this  purpose,  Mr.  Hutchison  has  compiled 
a  table  (deduced  from  the  examination  of  3,000  persons), 
from  which  the  following  figures  are  taken: 

o  in.  ought  to  weigh  about    92.26  lbs. 

115.52  " 

127.86  " 

139.17  " 

144.29  " 

157.76  " 

170.86  " 

177.25  " 

218.66  " 

2.  Development  and  Muscularity. — To  be  typical  of  per- 
fect health,  the  various  parts  of  the  body  must  be  accu- 
rately proportioned  one  to  another.  A  moderate  amount 
of  adiposity  is  quite  consistent  with  health,  provided  that 
the  muscular  system  is  correspondingly  developed.  Gene- 
rally, as  age  advances,  the  tendency  to  the  deposit  of  fat 
increases,  and  this  must  be  borne  in  mind.  At  the  same 
time,  its  rapid  accumulation,  after  fifty  years  of  age,  is  not 
a  symptom  of  health.  Spare  people  are  often  the  longest 
livers. 

The  presence  of  certain  obvious  morbid  conditions  may 
be  noted  at  this  stage. 


A  man 

of 

4 

ft. 

6  in. 

to 

5 

ft. 

0 

5 

0      ' 

5 

I 

5 

2      ' 

5 

3 

5 

4      ' 

5 

5 

5 

6      ' 

5 

7 

5 

8      ' 

5 

9 

5 

10      ' 

5 

II 

5 

II      ' 

6 

0 

6 

0 

, 

•  •  • 

.  ^ 

1 8  MEDICAL   DIAGNOSIS. 

3.  Changes  in  the  Color  of  the  Skin. 

(a.)  Palloj'  is  due  to  defective  filling  of  the  capillaries,  to 
deficiency  in  the  quantity  of  the  blood,  or  of  the  haemoglo- 
bin it  contains.  Pallor,  consequently,  may  arise  from  any 
condition  which  prevents  the  proper  assimilation  of  the 
food  (dyspepsia,  etc.) ;  from  any  interference  with  the  forma- 
tion of  the  blood  (chlorosis,  anaemia,  etc.);  from  any  dis- 
ease leading  to  loss  of  blood  (hemorrhage),  or  its  nutritive 
materials  (Bright's  disease),  or,  finally,  from  any  affection 
of  the  vascular  system  interfering  with  the  proper  propul- 
sion of  the  blood  (mental  emotions,  fatty  heart,  mitral  dis- 
ease, etc.).  Pallor  occurs  in  connection  with  all  grave  or- 
ganic diseases,  such  as  cancer  and  tuberculosis.  The  pale- 
ness of  the  skin  can  best  be  appreciated,  if  it  is  slight,  on 
the  ears,  cheeks,  eyelids,  or  lips. 

{b?)  Redness  of  skin  beyond  the  natural  tint  first,  and  prin- 
cipally, shows  itself  at  those  points  which  have  just  been 
mentioned  in  connection  with  pallor;  but  it  must  be  borne 
in  mind  that  those  persons  who  are,  by  reason  of  their  occu- 
pation exposed  to  heat,  or  to  the  weather,  are  usually  ruddy 
in  complexion.  Apart,  however,  from  these  causes,  redness 
occurs  either  as  a  result  of  increase  of  the  amount  of  blood  in 
the  body,  or  of  its  haemoglobin  (as  is  seen  in  "full-blooded  " 
plethoric  persons),  or  is  due  to  dilatation  of  the  capillaries. 
The  latter  cause  accounts  for  the  blushing  caused  by  men- 
tal emotion,  as  well  as  that  following  the  inhalation  of  ni- 
trite of  amyl;  and  in  a  similar  way  may  be  explained  the 
redness  of  the  scalp  and  face  in  hemicrania,  and  the  gene- 
ral redness  of  inflammation,  and  of  fever. 

(<f.)  Cyanosis  {uvaro?,  blue),  or  blueness  of  the  skin,  va- 
ries much  in  degree.  It  is  first  noticeable  on  the  lips, 
cheeks,  conjunctivae,  ears,  and  point  of  the  nose  and  fingers, 
but  may  become  very  general.  It  always  arises  from  the 
presence  of  too  much  carbonic  acid  in  the  blood.  This  may 
be  caused  by  interference  either  with  the  respiratory  or 
with  the  vascular  functions.  Anything  which  prevents  the 
free  access  of  air  to  the  blood  circulating  in  the  lungs  will 
cause  cyanosis,  and  hence  this  condition  may  arise  in  almost 
all  laryngeal  and  pulmonary  diseases.  Cyanosis  also  at- 
tends diseases  of  the  heart,  whether  congenital  malforma- 
tions or  valvular  affections;  and  may  also  be  produced  by 
spasm  of  the  arterioles,  as  in  chilling  of  the  surface. 

(d.)  Jaundice^  or  yellow  discolorations  of  the  skin,  results 
from  the  absorption  of  bile  into  the  circulation.     It  shows 


CONDITION   AND   CIRCUMSTANCES   OF  A  PATIENT.    IQ 

itself  first  under  the  conjunctivae;  but  the  observer  must 
not  mistake  for  jaundice  the  yellow  color  of  small  masses 
of  fat  which  may  be  deposited  there  in  advanced  life.  It 
is  usual  to  divide  jaundice  into  two  varieties:  (i.)  Hepato- 
genic^ or  mechanical,  which  results  from  obstruction  of  the 
gall  duct  by  catarrh,  concretions,  parasites,  pressure  of  tu- 
mors, etc.,  from  compression  of  the  smaller  branches  of  the 
duct  in  the  liver  substance,  either  from  interference  with 
the  portal  circulation,  or  in  such  diseases  as  cirrhotic,  wax}'-, 
or  fatty  liver.  (2.)  HcEjnogenic^  arising  from  abnormal  con- 
ditions of  the  blood  itself.  To  this  class  belongs  the  jaun- 
dice which  follows  the  inhalation  of  chloroform  or  ether, 
and  possibly  that  met  with  in  typhus,  yellow  fever,  acute 
yellow  atrophy  of  the  liver,  etc. 

(<?.)  Bronzing  occurs  in  Addison's  disease  (disease  of  the 
suprarenal  capsules).  Large  tracts  of  the  skin  become 
bronzed,  usually  on  face,  neck,  back  of  the  hands,  and  spe- 
cially where  friction  or  pressure  is  most  felt.  The  con- 
junctivae are  never  discolored.  Smaller  and  more  sharply 
defined  patches  of  pigment  are  sometimes  seen  in  preg- 
nancy, and  in  disease  of  the  generative  organs  in  the  fe- 
male. Local  pigmentation  is  often  the  result  of  external 
irritation  (blisters,  etc.),  and  in  Pityriasis  versicolor  the  pres- 
ence of  the  parasite  Microsporon  furftir  gives  rise  to  a 
brown  discoloration. 

(/.)  Gray  discoloration  of  the  skin  (argyria)  occurs  after 
the  prolonged  use  of  nitrate  of  silver. 

{^Skin  eruptions  are  noticed  further  on). 

(Edema  arises  from  the  collection  of  serous  fluid  under 
the  skin.  The  swelling  usually  commences  at  the  ankles 
— at  first  appearing  only  in  the  evenings,  to  disappear  after 
the  night's  rest — it  may  increase  to  a  very  great  extent,  the 
limbs  becoming  much  distended,  pale,  smooth,  and  glossy. 
The  finger  pressed  upon  the  skin  leaves  a  deep  indentation 
when  removed  (pitting).  In  well-marked  cases  the  external 
genitals  become  greatly  swollen.  Occasionally  the  oedema 
makes  its  first  appearance  in  the  lower  eyelid,  then  usually 
arising  from  the  acute  inflammatory  form  of  Bright's  dis- 
ease.    QEdema  may  arise — 

I.  From  obstruction  to  the  return  of  venous  blood  to  the 
heart.  In  this  way  it  may  occur  in  almost  all  diseases  of 
the  heart,  and  in  some  pulmonary  affections,  particularly 
emphysema.     Pressure  on    the    inferior  vena  cava  in  the 


20  MEDICAL  DIAGNOSIS. 

abdomen,  from  an  enlarged  liver  or  tumor  of  any  kind,  or 
on  the  veins  of  the  leg  may  give  rise  to  oedema;  and  local 
oedema  is  common  round  abscesses. 

2.  From  alteration  in  the  coats  of  the  vessels  arising  from 
a  blood  supply  defective  in  amount  or  in  quality.  Under 
this  heading  fall  the  so-called  hydraemic  dropsies  seen  in 
diseases  of  the  kidneys,  in  anaemia,  and  in  many  wasting 
diseases. 

Emphysema  {Gr. efxcpvffaGo,  to  inflate)  of  the  skin  is  pro- 
duced by  a  collection  of  gaseous  fluid  in  the  subcutaneous 
cellular  tissue.  The  skin  pits  very  slightly  on  pressure, 
and  there  is  a  curious  and  unmistakable  feeling  of  crackling 
under  the  finger.  Apart  from  surgical  causes,  emphysema 
occurs  as  the  result  of  loss  of  continuity  in  the  air  passages 
or  at  some  portion  of  the  alimentary  tract.  Ulceration  or 
wound  of  the  larynx  or  trachea  may  give  rise  to  emphy- 
sema, but  it  more  commonly  results  from  rupture  of  one  or 
more  air  vesicles  in  the  lung.  In  the  latter  case  the  air  is 
effused  into  the  interlobular  septa,  and  under  the  visceral 
pleura  passes  back  to  the  root  of  the  lung,  thence  to  the  me- 
diastinal cellular  tissue,  and  finally  appears  in  the  jugular 
fossa,  and  passes  under  the  skin  of  neck  and  chest.  Perfora- 
tion of  the  oesophagus  from  whatever  cause  is  liable  to  occa- 
sion subcutaneous  emphysema,  and  ulceration  of  stomach  or 
intestines  may  likewise  allow  of  the  escape  of  air  under  the 
skin  if  these  structures  have  been  previously  glued  to  the 
abdominal  walls  by  adhesions. 

Perspiration. — Increased  perspiration  (hyperidrosis)  may 
be  general  or  local.  In  some  nervous  affections  it  has  been 
seen  to  be  limited  to  one  lateral  half  of  the  body  (hemidro- 
sis).  In  very  many  diseases  general  hyperidrosis  may  be 
observed,  and  furnishes  sometimes  an  indication  of  consid- 
erable importance.  Such,  for  example,  is  the  perspiration 
which  occurs  in  almost  all  organic  diseases  in  the  stage  of 
collapse,  and  that  which  follows  the  crisis  of  continued 
fevers  (critical  sweat).  One  of  the  stages  of  ague  is  that  of 
profuse  perspiration,  and  the  night  sweats  of  phthisis  are 
among  its  most  distressing  symptoms.  In  acute  rheuma- 
tism the  skin  is  habitually  moist,  and  usually  whenever 
there  occurs  considerable  dyspnoea,  from  whatever  cause, 
it  is  accompanied  by  perspiration.  It  must  not  be  forgot- 
ten that  strong  mental  emotions  (fear)  may  produce  copious 
sweating. 


CONDITION   AND   CIRCUMSTANCES   OF  A   PATIENT.    21 

Diminution  of  perspiration  is  seen  locally  in  many 
chronic  skin  affections;  and  generally  in  almost  all  condi- 
tions of  pyrexia,  in  diabetes,  and  sometimes  in  the  cirrhotic 
form  of  Bright's  disease. 

Finally,  the  perspiration  may  be  colored  yellow  from  the 
presence  of  bile  pigments  in  cases  of  jaundice,  and  in 
uraemia  it  may  hold  in  solution  large  quantities  of  urea. 
In  certain  rare  cases  it  has  been  observed  to  have  a  blue 
color  (the  cause  of  v^hich  is  as  yet  doubtful),  and  still  more 
rarely  extravasation  of  blood  on  to  the  surface  of  the  skin 
has  been  observed. 

The  Expression  of  the  Face  is  often  characteristic  of  the 
disease  under  which  the  patient  is  laboring.  The  pallor  of 
anaemia  and  of  carcinoma,  the  blueness  of  cyanosis,  and  the 
puffiness  of  renal  disease  have  already  been  alluded  to. 
In  addition,  we  may  mention  the  drawing  up  of  the  upper 
lip  in  acute  peritonitis,  the  flush  over  the  malar  bones  in 
cases  of  acute  pneumonia  and  of  hectic  fever,  the  squint 
of  hydrocephalus,  and  the  prominence  of  the  eyeball  of 
Graves'  disease.  In  the  typhoid  state  the  countenance  is 
dull,  motionless,  and  without  expression,  and  the  lips  and 
teeth  are  covered  with  sordes;  while  in  the  stage  of  col- 
lapse of  cholera,  the  face  is  sunken,  wrinkled,  the  eyeballs 
retracted,  and  the  skin  livid.  One  more  expression  we 
may  allude  to — the  hippoc7'afic,  that,  namely,  which  immedi- 
ately precedes  death.  The  face  is  pale  and  leaden,  the  eyes 
sunken,  the  eyelids  separated,  the  cornea  less  transparent 
than  natural,  the  nose  sharp  and  pinched,  and  the  lower 
jaw  falling. 

Temperament,  Constitution,  or  Diathesis. — Many  persons 
show  in  their  general  appearance  that  they  have  a  consti- 
tution which  is  liable  to  certain  forms  of  disease.  The 
recognition  of  such  peculiarities  of  appearance  may  be  of 
great  importance  in  cases  in  which  it  is  difficult  or  impossi- 
ble to  obtain  satisfactory  information  regarding  the  family 
history.  The  more  important  of  these  varieties  will  here 
be  sketched  in  outline.* 

I.    The  SangutJie  Constitution. — Body  well  developed,  head 

*For  this  outline  the  author  is  much  indebted  to  the  courtesy  of  Pro- 
fessor Grainger  Stewart,  from  whose  unpublished  lectures  it  has  been  in 
part  derived. 


22  MEDICAL  DIAGNOSIS. 

large,  teeth  massive  and  good,  complexion  ruddy,  hair  thick, 
digestion  and  nutrition  good,  pulse  hard,  blood  pressure 
high.  In  later  years  the  body  becomes  corpulent,  and  the 
signs  of  old  age  come  on  prematurely.  Such  persons  are 
liable  to  arthritic  affections  of  all  kinds,  and  to  diseases  of 
the  heart  and  blood-vessels  (angina,  fatty  heart,  aneurism, 
atheroma,  apoplexy,  etc.). 

2.  The  Nervous  Constitution. — Figure  small  and  wiry,  face 
mobile,  features  small  and  delicate,  great  activity  of  mind 
and  body,  c^iyspeptic,  and  with  highly  strung  nervous  sys- 
tem. Individuals  of  this  temperament  are  specially  liable 
to  nervous  diseases  of  all  kinds. 

3.  Strumous  Constitution. — The  whole  osseous  system  badly 
developed,  joints  enlarged,  mucous  membranes  irritable, 
upper  lip  and  alae  nasi  thick,  thorax  contracted,  skin  pale 
and  delicate,  and  hair  thin.  Such  persons  are  liable  to  dis- 
eases of  bones,  lymphatic  glands,  and  to  tubercle  in  all  its 
forms. 

4.  Lymphatic  Constitution. — Body  large  and  clumsy,  muscles 
flaccid,  face  pale  and  expressionless,  movements  slow,  and 
functions  both  of  body  and  mind  sluggish. 

5.  Bilious  Constitution. — Face  oval,  long  upper  lip  and 
chin,  long  nose,  complexion  dusky,  digestion  sluggish,  liver 
in  particular  being  inactive,  nervous  system  not  highly 
strung.  In  its  further  developments  this  constitution  passes 
into  melancholic,  where  the  patient  takes  gloomy  views  of 
things  in  general.  Such  persons  are  liable  to  melancholic 
insanity. 

6.  Gouty  Constitution. — Hair  early  gray,  little  tendency  to 
baldness;  nose  short,  rounded,  and  red;  cheeks  ruddy,  eyes 
generally  dark,  teeth  large  and  covered  with  thick  enamel, 
digestion  bad,  suffers  much  from  dyspepsia,  heart  tends  to 
degenerative  changes,  arteries  atheromatous,  arcus  senilis 
appears  early  and  is  well  marked.  Persons  of  this  consti- 
tution are  liable  to  all  the  forms  of  gout,  to  the  cirrhotic 
form  of  Bright's  disease,  to  neuralgia,  and  to  apoplexy. 

7.  Rheu7natic  Constitution  closely  resembles  the  sanguine, 
as  already  described.  There  is,  however,  in  it  a  greater 
tendency  to  fulness  of  body  and  less  general  vigor.  The 
teeth  are  liable  to  early  decay. 

Of  the  other  constitutions,  such  as  the  malarious,  the 
hsemorrhagic,  and  the  alcoholic,  the  limits  of  these  pages 
do  not  allow  allusion,  nor  need  the  numerous  mixed  forms 
be  specially  noticed. 


CONDITION   AND    CIRCUMSTANCES    OF  A   PATIENT.    23 

Attitude. — The  attitude  of  the  patient  is  very  frequently  de- 
termined by  the  disease  from  which  he  suffers.  For  exam- 
ple, at  the  height  of  a  severe  fever,  the  patient  may  be  seen 
lying  on  the  back  very  flat,  with  the  face  turned  upwards; 
and  one  of  the  first  indications  of  improvement  is  his  wish 
to  be  turned  on  to  his  side.  The  round-shouldered  appear- 
ance of  the  asthmatic  and  emphysematous  is  characteristic; 
and  in  bed  those  who  suffer  from  dyspnoea  are  usually 
obliged  to  be  propped  up.  Again,  a  patient  suffering  from 
acute  peritonitis  lies  with  his  knees  drawn  up;  and  so 
with  all  diseased  conditions,  almost  every  one  of  which 
compels  the  assumption  of  some  more  or  less  characteristic 
attitude. 

Evidence  of  Previous  Injury  or  Disease. — Apart  from  the 
obvious  traces  .of  such  surgical  affections  as  fractures,  etc., 
it  is  always  of  importance  to  note  any  indications  of  pre- 
vious disease  which  may  meet  us  in  the  course  of  our 
examination.  The  pitting  of  smallpox,  the  cicatrices  over 
scrofulous  glands,  the  large  joints  of  those  who,  in  their 
childhood,  have  been  subject  to  rickets,  old-standing  par- 
alyses, are  among  these  indicatiens.  Perhaps  the  most 
important  are  the  signs  of  former  syphilis,  such  as  fissures 
at  the  angles  of  the  lips,  cicatrices  on  the  palate,  adhesions 
of  the  iris,  traces  of  skin  eruptions,  nodes  on  the  skull  or 
tibiae,  etc.  Congenital  syphilis  may  be  recognized  late  in 
life  by  various  indications,  among  which  are  pallor,  de- 
pression of  the  bridge  of  the  nose,  pegged  teeth,  prom- 
inent forehead,  deafness,  nodes  on  bones,  keratitis,  cica- 
trices of  old  ulcers,  falling  out  of  hair  on  head  and  eye- 
brows, etc. 

Temperature. — The  thermometer  used  for  estimating  the 
tem.perature  of  the  body,  ought  to  be  of  such  a  size,  and  so 
divided  that  tenths  of  a  degree  can  easily  be  read  off;  it 
ought  to  have  an  arrangement  for  maximum  registration; 
the  purchaser  of  a  clinical  thermometer  should  see  that  the 
accuracy  of  the  instrument  in  question  has  been  tested  by 
comparison  with  a  standard  thermometer. 

It  is  most  usual  to  take  the  temperature  by  placing  the 
instrument  (the  index  having  been  first  jerked  down  below 
the  normal  point)  in  the  axilla,  the  skin  of  which  region 
must  be  carefully  dried,  should  there  have  been  any  per- 
spiration.    To    give    reliable   readings,    the    thermometer 


24  MEDICAL  DIAGNOSIS. 

ought  to  remain  in  position  for  fifteen  to  twenty  minutes, 
and  during  the  last  five  minutes  its  height  should  be  several 
times  examined,  in  order  to  see  if  it  remains  stationary,  or, 
not  having  reached  its  highest  point,  is  still  rising.  In  the 
latter  case  it  ought  to  be  allov^ed  to  remain  longer,  until 
no  farther  elevation  takes  place.  Still  more  accurate  re- 
sults are  to  be  obtained,  and  in  shorter  time,  when  the  in- 
strument is  passed  into  the  rectum.  In  children  the  tem- 
perature is  more  readily  taken  in  the  mouth,  the  bulb  of 
the  instrument  lying  under  the  edge  of  the  tongue. 

In  all  cases  of  importance  the  temperature  ought  to  be 
taken  twice  a  day,  morning  (9  to  ii  a.m.)  and  evening  (5  to  7 
P.M.),  and  in  serious  cases  every  two  hours.  From  the 
data  so  obtained  charts  should  be  constructed  in  the  usual 
manner. 

While  the  mean  normal  temperature  may  be  taken  to  be 
98.6°  of  Fahrenheit's  scale,  yet  variations  from  97.5°  to  99.5° 
are  met  with  in  healthy  persons.  When  the  mercury 
stands  below  the  former  point,  however,  it  usually  indi- 
cates a  state  of  collapse.  Above  99.5°  the  thermometer 
indicates  a  condition  of  fever,  which,  when  it  surpasses 
105°,  is  spoken  of  as  hyperpyrexia.  More  important  for 
diagnosis  than  the  actual  reading  is  the  manner  in  which 
the  temperature  rises.  Four  types  of  temperature  curves 
are  to  be  distinguished. 

1.  Continued. — The  temperature  rises  rapidly  and  almost 
continuously  to  a  given  height,  at  which  it  remains  during 
the  time  the  fever  lasts,  subject  only  to  such  slight  differ- 
ences between  morning  and  evening  temperature  as  may 
be  observed  in  health,  and  then  it  falls  to,  or  even  below, 
the  normal  point,  as  suddenly  as  it  rose.  This  rapid  fall, 
which  is  coincident  with  the  commencement  of  convales- 
cence, is  denominated  crisis.  This  type  is  met  with  in 
typhus,  smallpox,  measles,  etc.,  but  is  perhaps  best  marked 
in  acute  lobar  pneumonia. 

2.  Reifiittent. — In  this  variety  the  difference  between  the 
morning  and  evening  temperatures  is  considerable  (say 
2°  F.  or  more).  Hectic  fever  in  all  its  forms  is  perhaps  the 
the  best  example,  and  it  is  to  be  noted  that  occasionally 
(especially  in  phthisis)  the  ordinary  state  of  matters  is  re- 
versed, the  morning  temperature  being  high,  and  the  even- 
ing low.  During  the  first  few  days  of  typhoid  fever  the 
temperature  rises  in  a  characteristic  manner,  each  morning 
remission  being  considerably  under  the  temperature  of  the 


ALIMENTARY    SYSTEM.  2$ 

preceding  night,  but  above  that  of  the  preceding  morning 
(In  typhus  fever,  as  a  rule,  the  rise  is  more  sudden.)  In 
well-marked  examples  of  this  type  of  fever  temperature, 
when  the  disease  takes  a  favorable  turn  the  re-establish- 
jpnent  of  the  normal  temperature  takes  place  very  gradually, 
and  the  slow  fall  of  temperature  is  called  /ysis,  to  distin- 
guish it  from  the  more  rapid  crisis  of  which  we  have 
already  spoken. 

3.  Intermittent. — This  type  is  seen  in  the  different  forms 
of  ague.  The  temperature  rises  with  great  rapidity  to  a 
very  high  point,  and  falls  again  in  a  few  hours  to  normal. 
There  then  follows  a  period  of  intermission,  when  the  con- 
dition of  the  patient  is  normal,  and  then  again,  the  tem- 
perature rises  as  before,  and  so  on.  The  intervals  vary  in 
duration  according  to  the  type  of  ague  present,  lasting 
twenty-four  hours  in  quotidian,  forty-eight  in  tertian,  and 
seventy-two  in  quartan  ague. 

4.  Relapsing  or  Recurrent  Type. — After  a  rigor  the  tem- 
perature rises  to  a  high  point,  near  which  it  remains  for 
some  days,  and  then  falls  to  normal  (crisis).  An  interval 
of  immunity  from  fever  of  varied  duration  (five  to  eight 
days  or  longer)  succeeds  this  attack,  and  then  follows  a 
relapse  which  corresponds  very  closely  to  the  original 
attack.  These  relapses  may  occur  several  times  before  the 
disease  ceases. 


CHAPTER    11. 

Alimentary  System. 


Section  I. — Objective  Phenomena: — Lips — Teeth— Gums — Tongue — 
Secretions  of  Mouth — Fauces — Mastication — Deglutition — Examination 
of  CEsophagus.  Section  II. — Subjective  Phenomena: — Appetite — 
Thirst — Sensations  during  Fasting — Sensations  after  Eating — Pain — 
Acidity  —  Heartburn  —  Water-Brash  —  Flatulence  —  Eructation. 
Section  III. — Excretory  Phenomena: — Nausea  and  Vomiting — 
Examination  of  the  Vomited  Matter — Defaecation — Examination  of 
the  Faeces. 

The  signs  and  symptoms  in  connection  with  the  alimen- 
tary system  may  be  conveniently  considered  under  two 
sections.     The  first  of  these  contains  the  various  objective 


26  MEDICAL  DIAGNOSIS. 

phenomena  which  present  themselves  during  the  examina- 
tion of  organs  of  mastication  and  deglutition,  the  subjec- 
tive sensations  of  digestion,  and  the  phenomena  connected 
with  the  expulsion  of  the  food  from  the  body,  either  by- 
vomiting  or  by  defaecation. 

The  second  group  includes  all  these  physical  signs  which 
the  examination  of  the  abdomen  affords. 

The  first  of  these  sub-divisions  will  be  treated  of  in  the 
present  chapter. 

Section  I. 

Lips. — In  examining  the  lips  we  have  to  note — 
(a.)  Color. — Owing  to  the  great  transparency  of  the  labial 
epithelium,  any  change  in  the  color  of  the  blood  circulating 
in  the  minute  vessels  underlying  it  can  be  readily  distin- 
guished. When  the  lips  assume  a  dusky-blue  cyanotic* 
color,  we  know  that  the  circulation  is  being  carried  on 
imperfectly,  which  may  be  due  to  defective  circulation 
through  the  lungs,  or  to  interference  with  the  entrance  or 
exit  of  air  to  or  from  the  pulmonary  alveoli,  or  to  a  combi- 
nation of  these  two  causes.  The  lips  may  have  a  pale 
waxy  color,  indicating  that  the  amount  of  haemoglobin  is 
either  absolutely  less  than  normal,  as  in  cases  of  loss  of 
blood,  or  is  both  absolutely  and  relatively  (in  relation  to 
the  aqueous  constituents  of  the  blood)  below  the  normal 
standard,  as,  for  example,  in  chlorosis  and  other  forms  of 
anaemia,  as  well  as  in  many  cases  of  Bright's  disease. 

(^.)  Form. — Abnormal  thickness  or  thinness  of  the  lips 
gives  an  indication  of  the  amount  of  the  serum  contained 
in  the  interstices  of  the  tissues.  In  cases  where  this  is  ab- 
normally great,  without,  however,  any  appreciable  oedema 
(such  as  is  met  with  in  the  early  stages  of  Bright's  disease), 
the  lips  are  thick  and  pallid.  The  thin  pinched  lips  which 
are  seen,  for  example,  in  the  second  stage  of  cholera,  indi- 
cate an  abnormal  diminution  of  interstitial  lymph.  Her- 
petic eruptions  upon  the  lips  (herpes  labialis)  occur  in  fev- 
erish conditions,  particularly  in  pneumonia;  and  in  syphilis 
deep  and  painful  fissures  are  often  met  with.  When  we 
find  the  lips  dry,  cracked,  and  coated  with  sordes,  as  in 
most  febrile  conditions,  we  know  that  the  patient  has  been 
breathing  through  the  mouth,  this  causing  (in  combination 

*  From  the  Greek  nvavo'i^  bluCo 


ALIMENTARY    SYSTEM. 


27 


with  the  raised  temperature)  an  abnormally  rapid  evapora- 
tion of  the  saliva  which  in  health  keeps  the  lips  moist.* 
The  result  of  this  rapid  evaporation  is  that  the  solid  con- 
stituents of  the  saliva  are  deposited  on  the  lips  in  the  form 
of  sordes,  whilst  the  cracking  is  due  to  the  unequal  con- 
traction of  the  epithelial  layer  in  the  act  of  drying.  The 
fact  of  the  mouth  being  kept  constantly  open  for  the  pur- 
pose of  respiration,  although  frequently  due  to  more  or  less 
complete  obstruction  of  the  nasal  passages,  may  also  result 
from  any  cause  which  interferes  with  the  proper  oxygena- 
tion of  the  blood;  the  natural  tendency  in  such  cases  being 
to  attempt  to  increase  the  quantity  of  air  respired.  All 
dyspnoeic  patients,  therefore,  tend  to  breathe  through  the 
mouth,  as  offering  a  freer  passage  for  the  ingress  of  air  than 
the  nostrils.  The  fur  on  the  lips  occurs  under  similar  con- 
ditions as  does  that  upon  the  tongue,  which  will  be  present- 
ly described  in  detail. 

(c.)  Move7nents. — The  lips  being  among  the  principal  or- 
gans of  expression  of  the  emotions  and  the  will,  many  af- 
fections of  the  central  nervous  system  lead  to  trembling  of 
the  lips  (as  for  example,  delirium  tremens).  Abnormal  con- 
traction and  relaxation  of  the  labial  muscles  usually  mim- 
ics and  exaggerates  some  normal  expression.  The  risus 
sardontcus  of  tetanus  and  of  strychnine  poisoning  may  be 
taken  as  examples  of  this.  The  opposite  condition  is  seen 
in  the  expressionless  appearance  which  occurs  in  double 
facial  paralysis.  , 

Teeth. — The  two  sets  of  teeth  usually  appear  in  the  fol- 
lowing order: 


MILK  TEETH. 

Central  incisors,         .       7th  month. 
Lateral  incisors,  .       gth       *' 

First  molars,     .  .     15th       " 

Canines,  .  .     i8th      " 

Second  molars,  .     24th      " 

Usually  the  lower  central  incisors 
appear  first,  then  the  upper  central 
incisors,  and  after  them  the  lower 
lateral  incisors. 


PERMANENT    TEETH. 


Anterior  molars, 
Central  incisors, 
Lateral  incisors, 
Anterior  bicuspids, 
Posterior  bicuspids, 
Canines 


7th  year. 

8th     " 

9th     " 

loth     " 

nth     •' 

i2th     " 


Second  molars. 
Third  molars, 


1 2th  to  14th 
18th  to  25th 


It  is  important  to  observe  the  shape  of  the  teeth.    In  con- 
genital syphilis  the   central   incisors,  usually  of  the  upper 


*  The  amount  of  saliva  secreted  is  also  diminished  in  fever. 


28  MEDICAL  DIAGNOSIS. 

jaw  (permanent  teeth),  are  very  often  considerably  altered, 
as  was  originally  pointed  out  by  Hutchinson.  They  are 
shorter  and  narrower  than  natural,  notched  at  the  lower 
edge,  and  sometimes  grooved  down  the  centre,  and  set  at 
greater  intervals  in  the  gums  than  normal. 

Caf'ies  of  the  teeth  must  be  noted  as  bearing  upon  neu- 
ralgia, dyspepsia,  etc.  In  young  and  otherwise  healthy 
subjects  the  usual  cases  of  extensive  caries  of  the  teeth  is 
acidity  of  the  buccal  saliva,  arising  from  a  slight  catarrhal 
condition  of  the  mucous  membrane  of  the  mouth.  The 
continued  and  excessive  use  of  mercury  gives  rise  to  a 
looseness  of  the  teeth. 

Gums  and  Mucous  Membrane  of  the  Cheeks. — Like  the  lips, 
the  gums  show  by  an  anaemic,  bloodless  appearance  the 
presence  of  defective  circulation,  or  diminution  of  haemo- 
globin in  the  blood.  In  chronic  lead  poisoning  a  blue  Ime 
forms  on  the  gums  close  to  the  dental  margin,  caused,  in 
all  probability  by  deposit  of  sulphide  of  lead,  precipitated 
there  b)^  the  sulphuretted  hyd'rogen  generated  by  the  de- 
composition of  particles  of  food  remaining  about  the  teeth. 
Swelling  and  tenderness  of  the  gums,  along  with  the  loose- 
ness of  the  teeth  already  noted,  are  among  the  earliest  signs 
of  the  action  of  mercury.  Spongy  gums  which  readily 
bleed  are  met  with  in  cases  of  scurvy.  Inflammation  of  the 
gums  is  either  general  (stomatitis),  which  may  be  of  para- 
sitic origin  (muquet  or  thrush),  or  local,  constituting  gum- 
boil. Bleeding  may  also  result  from  the  sharp  angles  of 
carious  teeth,  or  from  the  coming  away  of  tartar  from  the 
teeth,  which  lacerates  neighboring  soft  parts.  Tn  paralysis 
of  the  buccinator  muscle  the  cheek  hangs  loose,  and  the 
food  collects  between  it  and  the  teeth.  This  condition  is 
seen  in  facial  and  bulbar  paralysis. 

Tongue. — In  examining  the  tongue  three  distinct  points 
have  to  be  considered — (i)  its  form,  (2)  its  movements,  (3) 
the  condition  of  its  surface. 

(i.)  Fo7'm. — In  health  the  tongue  varies  much  in  shape, 
and  this  without  any  particular  significance.  It  becomes 
swollen  from  various  causes,  particularly  inflammation,  the 
result  of  smallpox  or  scarlatina,  or  the  abuse  of  mercury 
or  other  drugs,  and  from  the  presence  of  cancerous  or  syphi- 
litic new  formations.  In  dyspepsia  the  tongue  has  frequent- 
ly a  swollen,  sodden  character,  marked  at  the  edges  by  the 


ALIMENTARY   SYSTEM. 


29 


teeth  against  which  it  has  been  pressed;  and  even  without 
these  causes,  where  there  is  great  mental  hebetude  along 
with  defective  movement  of  the  organ  in  the  mouth,  such 
(Edematous  swelling  takes  place. 

(2.)  Afovements. — The  tongue  receives  its  motor  innerva- 
tion through  the  hypoglossal  nerve.  Spasm  of  the  lingual 
muscles  is  a  common  symptom  in  chorea,  hysteria,  eclamp- 
sia, epilepsy,  etc.  In  chorea  the  tongue  is  protruded  rap- 
idly, and  as  rapidly  withdrawn.  Tremor  of  the  tongue  is  a 
symptom  of  progressive  muscular  atrophy,  generally  par- 
alysis, and  bulbar  paralysis,  and  is  seen  in  delirium  tre- 
mens. 

Paralysis  of  the  tongue  is  frequent  in  cerebral  affections 
(hemiplegia  from  hemorrhage,  embolism,  etc.;  bulbar  par- 
alysis, general  paralysis,  the  advanced  stages  of  locomotor 
ataxia,  etc.).  In  unilateral  paralysis  the  tongue  when  pro- 
truded is  inclined  towards  the  diseased  side.  When  the 
paralysis  is  bilateral  the  tongue  is  relaxed,  wrinkled,  fibril- 
lary contractions  may  be  seen  on  its  surface,  and  the  speech 
becomes  inarticulate  and  unintelligible. 

(3.)  Surface  of  the  Tongue. — Note  first  its  condition  as  to 
moisture.  Whenever  a  patient  breathes  habitually  through 
the  mouth  *  there  is  a  tendency  to  dryness  of  the  tongue, 
as  well  as  of  the  lips  (as  has  been  already  stated),  because 
of  the  more  rapid  evaporation  of  the  saliva  and  buccal  mu- 
cus, which  usually  keep  these  parts  moist.  In  fever  this  is 
still  more  marked,  partly  because  there  is  then  diminished 
secretion  of  these  fluids,  and  partly  because  the  evapora- 
tion goes  on  more  quickly  on  account  of  the  elevation  of 
the  temperature.  In  order  to  prevent  this  dryness  the  pa- 
tient moistens  his  lips  with  water  at  very  short  intervals, 
and  hence  the  dry  tongue  is  not  always  present  even  in 
fever.  When  it  is  present  in  such  patients  it  shows  that 
thirst  is  not  being  felt,  and  is  an  indication  that  the  senses 
are  becoming  blunted  and  consciousness  is  being  lost. 
When  the  tongue  becomes  very  dry,  cracks  appear  on  its 
surface,  due  to  the  unequal  contraction  of  the  epithelium 
in  the  act  of  drying.  A  degree  of  dryness  of  the  tongue  is 
likewise  met  with  in  diabetes,  and  after  the  administration 
of  certain  drugs — atropine,  for  example. 

*  Either  on  account  of  obstruction  of  the  nasal  passages  or  from  any- 
thing which  interferes  with  the  proper  oxygenation  of  the  blood  (dyspnoea 
in  all  its  forms). 


30  MEDICAL  DIAGNOSIS. 

Fur  on  the  Tongue. — In  fever  when,  as  has  just  been  said, 
the  saliva  evaporates  quickly,  it  deposits  its  solid  constitu- 
ents upon  the  lips  and  tongue.  When,  however,  no  abnor- 
mal evaporation  is  taking  place,  the  fur  which  is  found 
upon  the  tongue  is  not  to  any  appreciable  extent  so 
formed.  It  then  consists  of  debi-is  of  food,  of  cast-off  epi- 
thelial cells,  and  of  masses  of  micro-organisms.*  These 
organisms  enter  the  mouth  in  the  air  or  in  the  food,  are 
caught  on  the  filiform  papillae,  to  which  they  firmly  adhere, 
and  there  multiply  with  great  rapidity.  The  fungiform 
papillae  are  too  smooth  to  afford  points  of  attachment,  and 
hence  they  are  usually  free  from  fur,  and  stand  out  red  and 
prominent.  In  scarlet  fever  these  papillae  are  more  than 
usually  conspicuous,  on  account  of  the  congestion  of  the 
mucous  membrane,  and  they  stand  out  distinctly  through 
the  creamy  fur  which  covers  the  rest  of  the  organ,  and 
hence  the  tongue  assumes  a  "strawberry"  appearance. 
The  fur  which  collects  on  the  lingual  surface  is  being  con- 
stantly detached  by  the  rubbing  of  the  tongue  against  the 
roof  of  the  mouth,  gums,  and  teeth;  and  as  during  sleep 
there  is  very  little  movement,  the  coating  is  always  thickest 
in  the  morning.  It  is  also  to  be  remarked  that  the  fur  col- 
lects most  where  the  tongue  is  roughest,  and  where  the 
movement  is  least  in  amount,  /.<?.,  the  centre  and  back  part. 
Increase  of  fur  may  result  from  any  condition  which 
diminishes  the  movements  of  the  tongue  on  the  palate  and 
gums,  such  as  dryness  of  the  mouth,  swelling  of  the  tongue, 
defect  of  the  palate,  or  disease  of  the  central  nervous  sys- 
tem (hemiplegia,  bulbar  paralysis,  etc.)  paralyzing  the 
lingual  muscles. 

But  in  addition  to  the  fur  which  adheres  to  the  tongue, 
the  cavity  of  the  mouth  often  affords  a  nidus  for  other 
forms  of  vegetable  organisms,  such  as  those  which  give 
rise  to  lactic  and  butyric  fermentation  of  sugar,  and  ace- 
tous of  wine.  By  far  the  most  important  of  these  is  the 
parasite  which  occasions  thrush,  the  so-called  Oidiu7n  albi- 
cans, which  Grawitz  has  lately  shown  f  to  be  identical  with 
the  Microderma  vini.  Thrush  is  usually  met  within  delicate 
children,  and  affects  the  inner  surface  of  the  lips,  and  the 


*  According  to  Butlin's  cultivation  experiments  (St.  Bartholomew's 
Hosp.  Rep.  XV.)  these  include  :  Micrococcus,  Bacillus  subtilis,  Sarcina 
venlriculi,  Spirochcete  Obei-meyerii,  Bacterium  termo,  and  a  form  of  Vibrio. 

\  Virch.  Arch.t  vols.  Ixx.  and  Ixxiii. 


ALIMENTARY    SYSTEM.  3 1 

mucous  membrane  of  the  mouth  generally.  Small  white 
points  first  form,  which  rapidly  increase  in  number,  and 
extend  in  area,  the  patches  appearing  like  curdled  milk. 
The  reaction  of  the  saliva  becomes  strongly  acid,  and  thus 
causes  intense  irritation  of  the  mucous  membrane  of  the 
mouth,  which  becomes  red,  swollen,  and  painful.  In  adults 
the  appearance  of  thrush  is  usually  of  ominous  import. 

The  color  of  the  tongue  varies  considerably  under  differ- 
ent conditions.  In  fever  it  is  generally  more  or  less  red- 
dened, and  it  may  become  blue  in  cyanosis,  or  pale  where 
anaemia  exists. 

Finally,  the  tongue  is  liable  to  be  the  seat  of  new  forma- 
tions— syphilitic  fissures,  ulcers,  and  deposits  are  frequently 
met  with,  and  cancerous  disease  of  that  organ  is  not  un- 
common. 

The  sense  of  taste  will  be  considered  under  the  nervous 
system. 

Saliva. — The  reactioii  of  the  mixed  saliva  found  in  the 
mouth  is  normally  alkaline,  but  it  becomes  acid  when 
retained  for  long  in  the  buccal  cavity,  in  dyspepsia,  and  in 
diabetes.  It  is  mixed  with  epithelium  and  leucocytes,  and 
often  contains  certain  vegetable  organisms  [Oidiuf?i).  A 
small  quantity  of  albumen  is  present  in  health,  and  may  be 
much  increased  in  disease.*  Certain  medicines  when  ad- 
ministered internally  appear  in  the  saliva.  In  particular, 
the  salts  of  iodine  and  bromine;  urea  is  also  sometimes 
present  in  cases  of.  uraemia,  but  bile  and  grape  sugar  are 
never  excreted  in  the  saliva.  In  disease  the  saliva  may  be 
increased  or  diminished. 

Increase  of  saliva  (salivation  or  ptyalism)  arises — 

1.  From  irritation  in  mouth  and  throat;  as  in  stomatitis 
(mercurial  or  simple),  gum-boil,  ulcers,  dentition,  sore 
throat,  etc. 

2.  From  irritation  in  stomach,  pancreas,  intestines, 
uterus;  as  in  cases  of  dyspepsia,  worms,  and  in  pregnancy. 

3.  From  neuralgia,  especially  of  the  face. 

4.  From  certain  diseases  of  the  brain,  medulla,  and  spinal 
cord.  In  insanity,  hydrophobia,  hysteria,  and  particularly 
in  bulbar  paralysis. 

*  In  catarrh  of  the  mucous  membrane  of  the  mouth,  the  buccal  mucus 
contains  large  numbers  of  epithelial  cells  and  leucocytes  and  a  great 
quantity  of  dissolved  albumen. 


32  MEDICAL   DIAGNOSIS. 

5.  From  the  action  of  certain  drugs,  in  particular,  mer- 
cury and  jaborandi, 

Difninution  of  saliva  is  chiefly  met  with  in  fevers  and  in 
diabetes.  It  occasionally  results  from  blocking  of  the  sali- 
vary duct  with  a  calculus.  It  may  also  be  diminished  by 
mental  emotions,  and  by  the  administration  of  certain 
drugs. 

Pauces. — To  examine  the  fauces  the  patient  must  be 
made  to  open  his  mouth  in  such  a  position  that  strong 
light  falls  on  the  back  of  the  throat.  In  most  cases  it  is 
necessary  to  depress  the  tongue  by  means  of  a  spatula  or 
large  spoon.  Having  obtained  in  this  manner  a  satisfac- 
tory view,  we  must  satisfy  ourselves  of  the  condition  of  the 
pillars  of  the  fauces,  with  the  tonsils  lying  between  them 
(in  health  barely  visible);  of  the  soft  palate  arching  upon 
either  side,  with  the  uvula  depending  from  the  centre;  and 
of  the  posterior  wall  of  the  pharynx  behind.  We  must 
look  for  enlargement,  inflammation,  or  ulceration  in  all 
these  parts,  and  for  changes  in  the  mucous  membrane 
covering  them.  Acute  catarrh  causes  redness  and  swelling 
of  the  fauces;  and  to  a  still  more  marked  extent  does  the 
inflammation  which  accompanies  scarlet  fever.  More 
chronic  inflammatory  conditions  give  rise  to  a  dark-red 
appearance  of  the  mucous  membrane,  in  which  the  follicles 
may  be  more  conspicuously  affected;  and  care  must  be 
taken  not  to  mistake  the  distended  mouths  of  follicles  for 
ulcers.  In  thrush  (muquet)  small  white  patches  like  cur- 
dled milk  are  scattered  over  the  fauces,  as  well  as  over  the 
mouth  generally;  and  in  these,  when  microscopically  ex- 
amined, filaments  and  spores  of  Oidium  albicans  can  be  seen. 
In  acute  tonsillitis  the  tonsils  are  much  swollen,  and  of  a 
dark-red  color.  Their  surface  is  nodulated,  and  covered 
with  mucus.  When  the  disease  becomes  chronic,  the  ton- 
sils are  frequently  marked  with  small  white  points  of  seba- 
ceous matter  projecting  from  the  follicles. 

Ulceration  of  the  throat  may  be  (i)  catarrhal;  (2)  follicu- 
lar (corresponding  to  the  follicles);  (3)  scarlatinal;  (4) 
syphilitic;  (5)  diphtheritic;  (6)  herpetic;  (7)  cancerous;  (8) 
result  of  the  action  of  hot  water,  of  acids,  alkalies,  or  other 
chemical  substances.  In  diphtheria  the  mucous  membrane 
is  swollen,  reddened,  and  covered  with  patches  of  a  grayish 
exudation,  which  become  matted  together  so  as  to  form  a 
false  membrane.     These  patches  are  most  frequently  met 


ALIMENTARY   SYSTEM.  33 

with  on  the  soft  palate  and  uvula,  but  often  extend  to  the 
tonsils,  pharynx,  etc.  The  mucous  membrane,  in  which 
this  exudation  is  embedded,  sloughs  and  separates,  leaving 
open  ulcers.  Abscesses  may  form  in  the  tonsils,  or  behind 
the  posterior  wall  of  the  pharynx.  In  the  latter  case,  the 
pharyngeal  wall  bulges  forward,  interfering  alike  with 
respiration  and  with  deglutition.  Such  retropharyngeal 
abscesses  usually  arise  from  disease  of  the  cervical  ver- 
tebrae, the  condition  of  which  must  be  carefully  examined. 
Very  rarely  carotid  aneurisms  may  bulge  in  this  direction. 

The  form  of  the  soft  palate  is  of  considerable  importance 
in  diagnosis.  Paralysis  may  be  partial  or  total.  In  the 
former  case  the  velum  droops  and  does  not  arch  when  the 
uvula  is  tickled,  and  the  uvula  is  usually,  though  not 
always,  bent  to  the  sound  side.*  This  condition  is  caused 
by  paralysis  of  the  levator  palati  and  the  azygos  uvulae, 
both  of  which  muscles  receive  their  nervous  supply  from 
the  facial  nerve  through  the  large  superficial  petrosal 
branch  and  Meckel's  ganglion;  and  as  this  nerve  leaves 
the  facial  at  the  geniculate  ganglion,  paralysis  of  one  side 
of  the  palate  shows  that  the  disease  of  the  seventh  nerve  is 
above  that  point. 

When  all  the  muscles  on  both  sides  are  paralyzed,  the 
soft  palate  becomes  loose  and  flapping,  the  speech  assumes 
a  peculiar  nasal  tone,  and  fluids  regurgitate  through  the 
nose  when  the  action  of  swallowing  is  attempted.  This 
total  paralysis  of  the  palate  occurs  in  bulbar  paralysis,  and 
in  various  affections  of  the  brain  and  spinal  cord.  Paresis 
of  the  muscles  of  the  palate  frequently  arises  after  diph- 
theria. 

Mastication  may  be  rendered  difficult  or  painful  by  the 
presence  of  inflammatory  affections  of  the  lips,  gums, 
cheeks,  or  tongue,  by  defective  teeth,  by  cancerous  or  other 
ulceration  of  those  parts,  or  by  paralysis  or  spasm  of  the 
muscles  employed  in  the  act.  The  buccinator  and  the 
orbicularis  oris  receive  their  motor  supply  from  the  seventh 
nerve;  and  when  that  nerve  is  paralyzed  the  food  accumu- 
lates between  the  cheek  and  the  teeth.  The  motions  of  the 
-tongue  are  affected  in  paralysis  of  the  hypoglossal  nerve. 
The  muscles  of  mastication  (masseters,  pterygoids)  are  in- 
nervated  from   the   motor  branch  of  the  fifth   nerve,  and 

*  Sanders,  Edinburgh  Medical  Journal ^  1866. 


34  MEDICAL   DIAGNOSIS. 

when  they  are  paralyzed  the  lower  jaw  hangs  down,  and 
proper  mastication  is  impossible. 

Deglutition  may  be  rendered  difficult  and  painful  by  vari- 
ous affections  of  the  mouth  and  tongue,  such  as  swelling, 
ulceration,  inflammation,  etc.,  but  apart  from  such  tempo- 
rary causes  it  may  arise  from  paralysis  of  various  groups 
of  muscles.  For  purposes  of  description  the  act  of  deglu- 
tition may  be  divided  into  three  stages:  (i)  The  gathering 
up  of  the  food  into  a  bolus  and  thrusting  it  through  the 
anterior  pillars  of  the  fauces.  (2)  Its  passage  through  the 
upper  part  of  the  pharynx  until  it  has  passed  the  orifice  of 
the  larynx.  (3)  Its  descent  through  the  lower  part  of  the 
pharynx  and  the  oesophagus.  The  first  stage  of  deglutition 
is  interfered  with  in  paralysis  of  the  hypoglossal  nerve,  for 
the  tongue  cannot  then  form  and  force  back  the  bolus  into 
the  fauces.  Such  paralysis  is  almost  invariably  of  central 
origin.  In  the  second  stage  of  deglutition,  disease  of  the 
facial  nerve  above  the  geniculate  ganglion,  by  causing 
paralysis  of  the  soft  palate,  allows  food  to  pass  into  the 
posterior  nares,  and  the  same  symptom  is  present  in  post 
diptheritic  paralysis,  in  syphilitic  ulceration  of  the  palate 
and  epiglottis,  and  in  cleft  palate.  This  second  stage  of 
swallowing  may  also  be  interfered  with  by  paralysis  of  the 
muscles  of  the  pharynx.  The  food  sticks  at  the  root  of  the 
tongue,  and  occasions  such  dyspnoea  as  to  require  its  re- 
moval by  means  of  the  finger,  and  fluids  pass  readily  into 
the  larynx.  Thus  paralysis,  rare  as  a  peripheral  disease,  is 
common  as  a  result  of  affections  of  the  pons  and  medulla, 
and  of  diseases  of  the  base  of  the  brain,  compressing  the 
cranial  nerves.  The  third  stage  of  deglutition  may  be  in- 
terfered with  by  mechanical  obstruction  of  the  oesophagus 
(impacted  foreign  bodies,  pressure  of  aneurism  or  other 
tumor,  simple  or  cancerous  stricture,  etc.),  or  by  paralysis 
of  the  muscles  of  the  oesophagus,  which  is  very  rare  as  an 
isolated  affection.  In  the  latter  case  solids  may  manage 
to  make  their  way  down  the  tube  by  their  own  weight. 
Spasm  of  the  oesophageal  muscles  sometimes  prevents  de- 
glutition in  cases  of  hysteria. 

Exaininatio7i  of  the  oesophagus  is  practically  limited  to 
mediate  palpation  by  means  of  the  oesophageal  bougie. 
It  is  most  convenient  for  the  purposes  of  diagnosis  to  use 
the  elastic  tube  of  a  stomach  pump.  The  tube  must  be 
softened  in  warm  water,  lubricated  (preferably  with  glycer- 


ALIMENTARY   SYSTEM.  35 

ine  or  white  of  Ggg),  and  passed  gently  over  the  back 
of  the  patient's  tongue,  being  guided  by  the  left  forefinger 
of  the  operator  over  the  epiglottis,  and  then  gently  and 
steadily  pushed  into  the  stomach.  Of  the  difficulties  and 
dangers  which  the  operator  may  meet  in  the  course  of  this 
exploration,  the  following  are  the  most  important:  The 
oesophagus  must  never  be  sounded  until  there  is  certainty 
that  no  aneurismal  tumor  is  pressing  upon  it,  into  which 
the  point  of  the  tube  might  be  forced.  In  ordinary  circum- 
stances there  is  but  little  danger  of  the  instrument  passing 
through  the  glottis  into  the  trachea,  but  whenever  paralysis 
and  anaesthesia  of  the  laryngeal  structures  exists  very  great 
care  must  be  taken.  It  is  hardly  necessary  to  warn  the 
student  of  the  danger  of  forcing  the  sound  through  the 
oesophageal  structures.  Such  an  accident  has  happened 
not  infrequently,  and  it  is  of  course  more  ready  to  occur 
when  the  walls  are  softened  by  cancerous  deposit. 
In  sounding  the  oesophagus  we  meet  with — 

1.  Pain. — If  the  pain  be  felt  again  and  again  at  the  same 
spot  it  indicates  a  local  process,  probably  of  an  inflam- 
matory nature.  The  presence  of  ulceration  may  be  con- 
jectured if  the  sound,  however  carefully  it  has  been  intro- 
duced, always  comes  away  smeared  with  blood. 

2.  Obstruction. — -This  may  be  caused  by  the  point  of  the 
sound  passing  into  a  diverticulum,  and  it  is  characteristic 
of  this  condition  that  the  instrument  sometimes  passes  with 
great  ease,  and  sometimes  is  absolutely  arrested.  Strictures 
of  various  kinds  also  prevent  the  passage  of  the  sound. 
The  purely  spasmodic  strictures  met  with  in  hysteria  may 
be  distinguished  from  those  due  to  organic  disease  by 
placing  the  hysterical  patient  under  the  influence  of  chlo- 
roform, when  an  instrument  which  before  was  obstinately 
resisted  now  passes  freely  into  the  stomach. 

Auscultation  of  the  oesophagus  is  occasionally  practiseji. 
The  stethoscope  is  to  be  applied  a  little  to  the  left  of  the 
spinal  column  in  the  cervical  or  dorsal  region,  and  the  sound 
listened  to  which  arises  in^the  oesophagus  when  the  patient 
swallows  water.  In  health  the  act  of .  deglutition  is  ac- 
companied with  a  short,  clear  gurgling  sound.  When,  how- 
ever, oesophageal  obstruction  exists,  this  sound  is  prolonged, 
and  altered  in  character  below  the  seat  of  the  stricture. 

Appetite. — Derangements  of  the  appetite  may  occur  both 


36  MEDICAL  DIAGNOSIS. 

in  general  diseases  and  in  local  affections  of  the  stomach 
and  intestines. 

Anorexia^  or  loss  of  appetite,  is  present  during  ail  acute 
febrile  diseases,  and  may  also  result  from  excessive  fatigue 
of  mind  or  body,  or  from  depressing  emotions,  such  as  pain 
or  grief,  as  well  as  from  the  use  of  narcotics  or  alcohol.  It 
is  also  caused  by  inflammatory  affections  of  the  stomach, 
cancer  of  the  gastric  walls,  constipation,  and  other  abnor- 
mal conditions  of  the  intestines. 

Boulimia,  or  excessive  appetite,  may  result  simply  from 
the  habit  of  over-eating,  or  may  be  due  to  the  presence  of 
worms  in  the  stomach  or  intestines.  It  is  also  present  in 
certain  chronic  imflammatory  conditions  of  the  gastric 
mucous  membrane,  and  is  a  prominent  symptom  in  the 
course  of  diabetes,  and  in  various  nervous  disorders  (insan- 
ity, hydrocephalus,  epilepsy,  hysteria,  and  hypochondriasis). 

Fica^  or  depraved  appetite,  in  which  the  patient  craves 
for  various  abnormal  and  even  disgusting  articles,  is  some- 
times met  with  during  pregnancy,  and  in  patients  suffering 
from  chlorosis  and -mania,  and  in  idiots.. 

Thirst  almost  invariably  attends  all  feverish  states  of  the 
system.  It  is  a  marked  symptom  in  diabetes;  and  in  irri- 
tative conditions  of  the  stomach  thirst  commonly  appears 
some  hours  after  eating. 

Sensations  during  Fasting. — In  the  atonic  form  of  chronic 
dyspepsia  there  is  frequently  before  meals  a  feeling  of  sink- 
ing in  the  epigastrium,  along  with  faintness.  Pain,  when 
the  stomach  is  empty,  may  sometimes  be  present,  due  to 
cancer  or  ulcer,  although  in  these  diseases  the  greatest  pain 
is  usually  after  food  has  entered  the  stomach.  Over-secre- 
tion of  gastric  juice  may  give  rise  to  pain  when  the  stomach 
is  empty,  which  is  then  usually  relieved  by  eating. 

Sensations  after  Eating. — Painful  sensations  after  food  is 
swallowed,  which  are  referred  to  the  gastric  region,  vary 
from  the  slightest  feeling  of  discomfort  or  oppression  up  to 
the  most  severe  agony.     The  pain  may  be  due  to — 

I.  The  Presence  in  the  Stomach  of  Irritating  Substances. — 
This  irritation  may  be  mechanical,  when  indigestible  food 
has  been  swallowed,  or  chemical,  from  the  presence  of 
corrosive  poisons.  In  its  slighter  forms  such  irritation  gives 
rise  merely  to  a  feeling  of  weight,  discomfort,  or  distention; 
in  its  graver  varieties  the  pain  is  very  great. 


ALIMENTARY   SYSTEM.  37 

2.  Organic  Diseases  of  the  Gastric  Wall. — Of  these  the 
most  important  are  cancer  and  gastric  ulcer.  In  both  of 
these  affections,  especially  in  the  latter,  pain  becomes  very- 
severe  almost  immediately  after  food  has  been  swallowed, 
and  continues  for  a  considerable  time,  though,  as  a  rule,  the 
patient  is  free  from  pain  when  the  stomach  is  empty.  In 
gastric  ulcer  the  pain  is  sometimes  sharply  localized,  and  is 
increased  by  external  pressure.  Extensive  organic  disease 
may,  however,  in  rare  cases,  run  its  course  without  pain. 

3.  Ab}iort7ialities  of  Secretion. — Acidity,  when  due  to  over- 
secretion  of  the  acid  element  of  the  gastric  juice,  or  to  fer- 
mentation of  the  partially  digested  contents  of  the  stomach, 
may  give  rise  to  pain.  In  the  latter  case  the  evolution  of 
gas,  by  causing  distension  of  the  walls  of  the  stomach,  or 
spasmodic  contractions  due  to  the  irritation  of  the  gastric 
mucous  membrane,  may  be  the  direct  factor  in  producing 
the  painful  sensations.  The  name  heartburn  has  been  given 
to  a  peculiar  pain  of  a  burning  character,  due  to  abnormal 
acidity  of  the  contents  of  the  stomach.  It  is  referred  to 
the  epigastrium,  and  spreads  upwards  to  the  pharynx. 

4.  Nervous  Causes. — Pain  in  the  stomach  is  occasionally 
of  a  purely  neuralgic  character,  occurring  most  usually  in 
chlorosis,  hysteria,  hypochondriasis,  and  perhaps  also  in 
gout.  In  such  cases  the  digestion  may  be  perfect.  The 
pain  is  frequently  relieved  by  firm  pressure,  resembling  in 
this  respect  the  pain  of  flatulence. 

Pain  in  the  abdominal  muscles,  and  in  the  transverse 
colon,  must  not  be  mistaken  for  gastric  pain. 

Acidity. — Acidity  manifesting  itself  by  pains  (heartburn 
in  particular),  eructation  of  gas,  and  sometimes  by  nausea 
and  vomiting,  may  arise  from  various  causes. 

1.  Over- Secretion. — Some  observers  are  of  opinion  that 
in  certain  nervous  conditions  a  secretion  of  gastric  juice 
greater  than  normal  is  produced,  as  in  "  nervous  dys- 
pepia,"  *  or  as  a  result  of  irritation  of  the  gastric  mucous 
membrane  from  cancerous  growths  or  ulcer;  and  that  in 
this  way  acidity  may  develop  itself. 

2.  From  Fer77ientation. — In  the  normal  condition  no  fer- 
mentation can  take  place  in  the  contents  of  the  stomach, 
on  account  of  the  strongly  acid  reaction  which  they  possess; 

*  It  appears  probable  that  in  these  cases  there  is  a  certain  amount  of 
gastric  congestion  and  subacute  catarrh. 


38  MEDICAL  DIAGNOSIS. 

but  whenever  this  acidity  is  sufficiently  diminished  fer- 
mentation may  set  in,  and  acetic,  butyric,  and  lactic  acids 
are  then  formed,  along  with  hydrogen  and  carbonic  acid 
gas.  This  condition  of  the  gastric  contents  favorable  to 
fermentation  may  arise  from  a  deficiency  of  the  gastric  juice 
in  quantity  or  quality,  or  from  the  introduction  of  large 
quantities  of  fermentable  food.  To  aid  in  distinguishing 
the  acidity  from  over-secretion  from  that  caused  by  fer- 
mentation, it  may  be  borne  in  mind  that  the  former  occurs 
in  an  empty  stomach  or  immediately  after  food,  whereas 
the  latter  does  not  attain  its  height  until  some  hours  after 
a  meal,  and  does  not  occasion  so  much  pain.  The  fluid 
(water-brash)  regurgitating  may  be  bland,  neural,  and 
tasteless. 

Flatulence. — The  collection  of  gas  in  the  stomach  and 
bowels  may  result  either  from  the  swallowing  of  air  or  from 
fermentative  changes.  It  usually  arises  as  a  result  of  per- 
version of  the  digestive  process  in  some  of  its  various 
actions.  When  it  reaches  a  considerable  degree  it  is  called 
tympanites  or  meteorism,  and  its  seat,  whether  in  the 
stomach  or  the  bowel,  may  be  determined  by  percussion,  as 
will  be  afterwards  explained.  Flatulence  is  frequently  ac- 
companied by  colic,  and  the  gas  is  expelled  either  through 
the  rectum  or  mouth.  Gaseous  eructations  have  been 
analyzed  at  various  times,  and  have  been  found  to  contain 
carbonic  acid  gas,  hydrogen,  marsh  gas,  olefiant  gas,  oxy- 
gen, and  nitrogen.* 

Nausea  and  Vomiting. — The  expulsion  of  the  contents  of 
the  stomach  in  vomiting  is  caused  by  the  forcible  contrac- 
tion of  the  abdominal  muscles,  diaphragm,  etc.,  the  gastric 
muscular  fibre  itself  remaining  inactive.  It  is  a  reflex  act, 
having  its  centre  in  the  spinal  cord.  This  reflex  centre  cor- 
responds apparently  to  a  considerable  portion  of  the  cord, 
and  includes  part  of  the  respiratory  centre.  Vomiting  is 
produced  in  various  ways:  (i)  By  an}'  disease  of  the  brain 
or  spinal  cord  which  involves  this  reflex  centre;  (2)  By  ex- 
cessive irritation  of  the  respiratory  centre,  in  violent  cough- 
ing, etc.;  (3)  By  the  presence  in  the  blood  of  any  sub- 
stances which  occasion  irritation  of  the  centre  or  of  the 
terminal   twigs  of  the  vagus,  such    as  effete   products   in 

*  Vide  analysis  by  Ewald  and  Rupstein,  Arch./.  Anat.  u.  Physiologic^ 
1874. 


ALIMENTARY   SYSTEM.  39 

uraemia,  emetics,  etc.;  (4)  By  irritation  of  the  vagus  or  its 
branches.  This  is  by  far  the  most  frequent  cause  of  vom- 
iting. It  is  thus  that  vomiting  is  to  be  explained  in  cases 
of  uterine  disease  or  pregnancy,  kidney  disease,  the  passage 
of  gall-stones,  tickling  of  the  soft  palate,  and,  above  all,  in 
affections  of  the  stomach  itself.  Chemical  or  mechanical 
irritation  of  the  gastric  mucous  membrane  gives  rise  to 
vomiting.  It  may  also  be  produced  by  fermentative  changes 
in  the  contents  of  the  stomach,  by  ulceration,  or  chronic 
catarrh  of  the  gastric  mucous  membrane.  There  is  no  dis- 
ease of  the  stomach  in  which  vomiting  may  not  be  present. 
Gastric  vomiting  is  usually  preceded  by  nausea  and  pain, 
and  bears  some  relation  to  the  food  swallowed;  whereas 
when  this  symptom  arises  from  irritation  of  other  kinds 
these  are  frequently  absent.  The  diagnostic  significance 
of  vomiting  can,  however,  be  best  appreciated  after  the 
examination  of  the 

Vomited  Matter. — This  consists  of  the  contents  of  the 
stomach  and  sometimes  of  the  duodenum.  The  fluids  and 
solids  vomited  are  more  or  less  acted  upon  by  the  gastric 
juice,  and  are  usually  strongly  acid.  Of  abnormal  sub- 
stances present  the  most  important  is  blood,  which  may  be 
almost  pure,  but  is  generally  more  or  less  acted  upon  by 
the  gastric  juice,  and  thereby  coagulated  and  blackened  so 
as  to  resemble  the  grounds  of  coffee.  Haematemesis  (the 
vomiting  of  blood)  is  most  frequently  produced  by  gastric 
ulcer;  but  it  also  occurs  in  blood  diseases  (yellow  fever),  in 
congestion  of  the  veins  of  the  stomach  (cirrhosis  of  the 
liver,  pressure  on  inferior  vena  cava),  and  sometimes  vica- 
riously, when  the  menstrual  flow  is  arrested,  and  finally,  it 
may  result  from  wounds  of  the  stomach,  or  from  the  burst- 
ing of  an  aneurism  into  the  stomach  or  oesophagus.  Bile 
is  frequently  found  in  the  vomited  matter,  rarely  pus, 
and  still  more  rarely  faecal  matter.  The  latter  usually 
points  to  intestinal  obstruction,  although,  according  to 
Bamberger,  it  may  occur  independently  of  such  condition 
when  the  bowel  is  paralyzed  as  a  consequence  of  peritonitis 
and  typhoid  fever.  Microscopic  exami?iafion  of  the  vomited 
matter  shows  the  various  substances  derived  from  the  food 
swallowed,  sometimes  SarcincE  veiitriculi  and  intestinal 
parasitic  worms  {Ascaris  lumbricoides,  etc.)  The  sarcincB  are 
small  cube-shaped  cells  united  in  groups  of  four.  They 
are  met  with  in  nearly  all  cases  in  which  food  remains  too 


40  MEDICAL  DIAGNOSIS. 

long  in  the  stomach  and  there  ferments,  particularly  in 
dilated  stomach.  Other  micro-organisms  may  also  be 
found,  but  are  of  less  importance,  so  far  as  our  present 
knowledge  goes. 

Defaecation. — While  normally  defaecation  occurs  once  in 
the  twenty-four  hours,  it  is  not  uncommon  to  find  persons 
who  have  two  motions  in  that  period,  or  whose  bowels  act 
only  once  in  two  days,  without  the  bounds  of  health  being 
overstepped.  In  infants  the  bowels  move  frequently — four 
or  five  times  a  day.  The  following  points  have  to  be  in- 
quired into: 

1.  The  Frequency  of  the  Motions,  and  the  period  at  which 
the  bowels  act  relatively  to  eating,  drinking,  exercise,  etc. 

2.  The  Chai'acter  of  the  Act  of  Defoecation. — Faintness  or 
sickness  may  precede  the  act,  which  may  itself  be  painful 
and  straining,  and  may  be  followed  by  a  sensation  of  the 
rectum  not  having  been  emptied  of  its  contents  (tenesmus). 
The  actual  condition  of  the  anus  and  rectum  must  be  deter- 
mined, and  the  presence  of  piles,  fissure,  prolapse,  ulcer- 
ation, etc.,  looked  for. 

The  two  conditions  of  constipation  and  of  diarrhoea  de- 
mand brief  notice. 

Constipation  may  result  from — 

1.  Mechanical  obstruction  ;  and  this  may  be  caused  in 
various  ways,  such  as  from  accumulations  of  various  kinds 
in  the  bowel,  by  cicatricial  or  cancerous  stricture,  by  exter- 
nal compression  of  the  intestines,  by  strangulation  or  in- 
tussusception, and  by  spasm  or  paralysis. 

2.  Defective  peristaltic  action. 

3.  Deficiency  of  the  secretions. 

These  two  last  causes  may  arise  from  too  frequent  use  of 
purgatives,  from  neglect  of  the  regular  performance  of  the 
act  of  defaecation,  from  the  abuse  of  opium,  from  sedentary 
and  from  enervating  habits,  as  well  as  from  derangement 
of  stomach  and  liver,  and  from  many  other  causes  too  nu- 
merous to  mention. 

Diarrhoea. — Among  the  causes  of  this  condition  are — 

1.  Irritation  of  the  bowels  by  improper  or  badly-digested 
food,  by  purgatives,  etc.,  or  by  retained  hardened  faeces,  or 
the  presence  in  the  bowels  of  noxious  materials  eliminated 
from  the  body,  in  various  diseases,  as  uraemia,  gout,  and 
fevers. 

2.  Diseases  of  the  bowels,  congestion,  inflammation,  etc. 


ALIMENTARY   SYSTEM.  4T 

Character  of  the  Faeces.* 

I.  Macroscopic  Characters. 

(rt-.)  Color. — The  normal  color  of  the  faeces  may  be  altered 
by  reason  of  the  food  eaten,  and  still  more  markedly  by 
medicines.  Iron  and  bismuth  when  taken  internally 
blacken  the  motions,  while  the  administration  of  prepara- 
tions of  iodine  causes  a  blue,  calomel  a  green,  and  logwood 
a  red-brown  color  to  appear  in  the  faeces.  If  all  these 
causes  of  altered  color  be  excluded,  then  the  alteration  is 
dependent  upon  bile  or  upon  blood.  The  presence  of  bile 
gives  rise  to  a  yellow  or  to  a  green  tint,  and  in  its  absence 
the  faeces  assume  a  gray  or  chalky  appearance.  Blood  in 
the  stools  may  possess  its  natural  appearance,  in  which 
case  it  has  probably  come  from  low  down  in  the  intestinal 
tract,  and  is  in  consequence  not  intimately  mixed  into  the 
substance  of  the  faeces,  but  merely  lies  on  the  surface.  If, 
however,  the  bleeding  point  lies  higher  up,  then  the  blood 
becomes  acted  upon  by  the  digestive  fluids,  and  assumes  a 
dark-brown  or  black  appearance  in  the  stools  (melaena), 
with  the  substance  of  which  it  is  intimately  mixed. 

(b?)  Reaction. — According  to  the  exhaustive  investigations 
of  Nothnagel,  the  reaction  of  the  faeces  is  variable,  but  is 
usually  alkaline,  almost  always  so  in  typhoid  fever.  In  the 
acute  catarrhal  enteritis  of  children,  the  stools  are  usually 
acid. 

(r.)  For7n  a?id  Consistence. — The  faeces  become  fluid  when 
the  intestinal  peristaltic  action  is  accelerated,  and  on  the 
contrary  in  constipation  they  may  assume  a  very  consider- 
able hardness.  The  presence  of  a  polypus  in  the  rectum 
may  impress  a  longitudinal  groove  upon  the  faecal  masses  ; 
and  when  there  is  narrowing  of  the  bowel,  particularly  of 
the  rectum,  the  faeces  are  usuall}"  thin,  long,  and  narrow. 

[d.')  The  Odor  of  the  faeces  has  not  been  shown  to  be  of 
diagnostic  significance. 

((?.)  Abnor??ial  Substances  visible  to  the  naked  eye. — Either  on 
account  of  their  owm  indigestibility,  or  from  interference 
with  digestion,  various  articles  of  food  may  appear  in  the 
faeces.  Of  importance  is  the  detection  of  gall  stones,  and 
when  their  presence  is  suspected,  the  faecal  matters  should 
be  carefully  washed  on  a  fine  sieve.  Shreds  of  mucous 
membrane,  polypi,  and  other  tumors,  are  occasionally  met 
with,  and  more  frequently  still  the  various  parasites  that 

*  See  Appendix  A. 


42  MEDICAL    DIAGNOSIS. 

inhabit  the  intestinal  tract.  The  round  worms  include  the 
Ascaris  Imnhricoidcs,  which  resembles  in  shape  a  common 
earth-worm,  the  Oxyitris  verffiicularis,  very  small  and  thin, 
like  a  piece  of  cotton  thread,  about  half  an  inch  long  ;  and 
the  Trichoccphaliis  dispar,  which  is  readily  recognized  by  its 
anterior  end  being  thin  and  thread-like,  while  the  posterior 
is  much  thicker.  It  measures  from  one  to  two  inches  in 
length.  The  three  common  varieties  of  tape  worms  are 
Tcenia  solium^  Tcenia  ■}nediocaneIlata^Both7'iocephaIus  latvs.  The 
latter  may  be  distinguished  from  the  two  first  by  the  fact 
that  the  sexual  openings  occur  in  the  middle  of  the  seg- 
ments, while  in  the  others  they  are  placed  at  the  border. 
The  Tania  solium  differs  from  the  Tcenia  7nediocanellata  in 
many  particulars,  the  most  obvious  being  its  possession  of 
from  twenty-six  to  thirty  booklets  on  the  head,  which  are 
absent  in  the  Tcenia  mediocanellata.  Echinococcus  cysts  are 
likewise  sometimes  found  in  the  stools.  Abnormal  quanti- 
ties of  mucus  and  bile  may  be  seen  ;  and  fat  in  large  amount, 
when  not  accounted  for  by  diet,  usually  indicates  affection 
of  liver  or  pancreas.  To  the  presence  of  blood  we  have 
already  alluded. 

Microscopic  Examination  of  the  Tceces. — Fragments  of  food, 
including  muscular  fibre,  connective  tissue,  fat  cells  and 
crystals,  coagulated  albumen,  vegetable  cells,  etc.,  are 
readily  to  be  detected  in  the  stools.  Besides  these,  we  hat^e 
to  recognize  certain  elements  which  are  derived  from  the 
tissues  themselves,  as  for  example,  epithelial  cells,  mucous 
and  pus  corpuscles,  blood  corpuscles  and  crystals  of  various 
forms — triple-phosphate,  cholesterin,  Charcot's  crystals, 
haemic  crystals,  and  balls  of  leucin.  In  the  stools  there 
also  may  be  found  many  vegetable  and  animal  parasites, 
the  former  including  Bacteriinn  termo,  Sarcina  ventriculi,  and 
similar  forms,  while  to  the  latter  belong  A 7/ice^a  co/i,  various 
infusoria,  and  the  eggs  of  the  parasitic  worms  already  de- 
scribed. 


CHAPTER  III. 

Examination  of  the  Abdomen. 

The  physical  examination  of  the  abdomen  can  only  be 
made  with  advantage  when  the  patient  is  in  the  recumbent 


EXyVMINATlON    OF   THE   ABDOMEN.  43 

posture.  It  is  well  to  have  the  shoulders  slightly  elevated 
by  means  of  a  pillow,  so  as  to  relax  the  abdominal  muscles, 
which  can  be  still  further  effected  by  causing  the  knees  to 
be  raised.  The  examination  is  conducted  by  means  of  in- 
spection, palpation,  percussion,  and  auscultation,  each  of 
which  will  be  considered  in  turn. 


Inspection  of  the  Abdomen. 

1.  General  Prominence. 

(a.)  Ascites. 
(d.)  Meteorism. 

2.  General  Retraction. 

(a.)  Inanition. 

(d.)  Wasting  Diseases. 

(c.)  Tubercular  Meningitis. 

3.  Local  Tumefaction  of  Various  Organs. 

4.  Abdominal  Movements. 

(a.)  Respiratory  Movements. 
(d.)   Pulsatory  Movements. 
(c.)  Peristaltic  Movements. 

The  form  of  the  abdomen  varies  greatly  within  physio- 
logical limits.  A  full  dietary  and  a  corpulent  habit  cause 
prominence  in  this  region,  whilst  in  old  age  and  after  pro- 
longed inanition  the  belly  sinks  in,  and  its  bony  walls  be- 
come unduly  prominent.  The  enlargement  of  the  abdo- 
men in  pregnancy  is  also  physiological. 

The  pathological  changes  which  inspection  indicates  may 
be  considered  under  three  heads — (i)  General  prominence, 
(2)  General  retraction,  (3)  Local  tumefaction. 

General  prominence  of  the  abdomen  is  found — 

1.  In  ascites,  where  an  effusion  of  fluid  has  taken  place 
into  the  peritoneal  sac.  The  fluid  gravitates  to  the  most 
dependent  position;  and,  consequently,  when  the  patient 
lies  on  his  back,  the  anterior  part  of  the  abdomen  is  flat- 
tened, while  the  sides  bulge,  whereas,  if  the  erect  position 
be  assumed,  the  prominence  is  greatest  in  the  h3^pogastric 
region. 

2.  In  meteorism,  or  accumulation  of  gas  in  the  intestines. 
In  this  case  a  change  in  position  does  not  affect  the  form 
of  the  abdomen,  which  is  more  spherical  than  in  the  former 
condition. 

When  the  abdomen  is  greatly  distended,  from  whatever 


44  MEDICAL  DIAGNOSIS. 

cause,  the  diaphragm  becomes  raised,  the  ribs  pressed  out- 
wards, and  the  position  and  character  of  the  apex-beat  of 
the  heart  altered.  The  abdominal  walls  become  smooth 
and  glistening,  the  recti  muscles  are  pushed  asunder,  and 
in  the  interval  between  them  the  peristaltic  motion  of  the 
intestines  may  occasionally  be  observed.  The  umbilicus 
rises,  first  of  all,  to  a  level  with  the  adjoining  skin,  and 
subsequently  protrudes  beyond  it.  The  pressure  exerted 
on  the  inferior  vena  cava  gives  rise  to  the  development  of 
the  collateral  venous  circulation  as  a  delicate  blue  network 
over  the  abdominal  parieties,  whilst  obstruction  to  the 
portal  circulation  occasions  distension  of  the  veins  at  the 
umbilicus — this  varicose  condition  being  the  more  observa- 
ble by  reason  of  the  prominence  of  the  navel. 

Retraction  of  the  abdominal  walls  is  met  with  in  cases  of 
inanition  from  whatever  cause  (particularly  in  oesophageal 
obstruction),  and  in  all  wasting  diseases.  It  is  also  seen  in 
various  diseases  affecting  the  nerve  centres  (tubercular 
meningitis),  and  is  then  attributed  to  contraction  of  the 
intestines,  determined  by  the  irritation  at  the  base  of  the 
brain. 

The  bony  walls  become  prominent,  and  the  vertebral 
column,  with  the  pulsations  of  the  aorta  lying  on  its  left 
side,  may  be  seen.  The  relaxed  abdominal  walls  form 
pendulous  folds,  between  which  friction  may  produce  ul- 
ceration of  the  skin. 

Local  tumefaction  may  occur  in  connection  with  various 
abdominal  organs  as  follows: 

Sto?nach. — Dilatation  of  this  viscus  gives  rise  to  an  oval 
swelling  occupying  the  epigastrium,  and  extending  chiefly 
towards  the  left.  The  position  of  the  greater  curvature 
may  be  indicated  by  a  diagonal  furrow  running  from  the 
right  downwards  and  to  the  left. 

The  outline  of  the  stomach  is  best  made  out  when  it  is 
artificially  distended,  according  to  the  method  originally 
recommended  by  Frerichs.  The  patient  is  made  to  swallow 
successively  a  solution  of  tartaric  acid,  and  one  of  bi- 
carbonate of  soda,  of  each  salt  as  much  as  may  be  carried 
on  the  point  of  a  table-knife.  The  result  of  the  mixture  of 
these  solutions  in  the  stomach  is  the  development  in  that 
viscus  of  a  large  quantity  of  carbonic  acid  gas,  and  conse- 
quent distension.*     In  a  few  seconds  the  position  of  the 

*  This  method  is  not  dangerous  to  the  patient,  provided  that  cases  of 
gastric  ulcer  be  excluded.     The  worst  symptoms  which  an   overdose 


EXAMINATION   OF  THE  ABDOMEN.  45 

greater  curvature,  and  the  general  outline  of  the  stomach, 
can  be  made  out  with  great  distinctness.  When  the  small 
intestine  and  colon  become  rapidly  filled  with  the  liberated 
gas,  we  may  with  safety  diagnose  incompetence  of  the 
pylorus,  resulting  from  ulceration  or  carcinoma,  or  perhaps 
occasionally  from  abnormal  innervation. 

Tumors  of  the  stomach  sometimes  cause  visible  promi- 
nence of  the  abdominal  wall.  They  do  not  alter  their  po- 
sition with  the  respiratory  movements,  and  may  thus  be 
readily  distinguished  from  tumors  of  the  liver  and  spleen, 
which  rise  and  fall  with  the  respiration. 

Liver. — In  the  healthy  adult*  the  liver  gives  rise  to  no 
visible  prominence  of  the  abdominal  walls.  When  enlarge- 
ment takes  place,  it  usually  shows  itself  first  under  the 
margin  of  the  ribs,  in  the  right  hypochondrium,  unless  the 
left  lobe  be  chiefly  affected,  when  the  tumefaction  appears 
in  the  epigastrium.  The  edge  of  the  liver,  or  the  tumor 
arising  from  that  organ,  when  visible,  may  be  seen  to  rise 
and  fall  with  the  respiratory  movements — an  important  di- 
agnostic point. 

Splenic  tumors,  when  of  large  size,  cause  visible  tumefac- 
tion of  the  abdomen  generally,  particularly  on  the  left  side. 

Tumors  of  the  kidneys  and  omentum  do  not,  as  a  rule,  cause 
visible  swelling. 

Ovarian  tumors  are  originally  lateral  in  position,  al- 
though they  may  develop  to  so  great  a  size  as  to  distend 
the  whole  abdomen. 

Abdominal  movements  other  than  those  of  normal  respira- 
tion may  be  seen — {a)  respirator)^,  {b)  pulsatory,  (c)  peris- 
taltic. 

The  respiratory  movements  affect  the  position  of  all  tumors 
which  are  attached  to  the  liver  or  diaphragm.  Splenic  tu- 
mors are  also  similarly  influenced,  but  to  a  less  degree. 
Tumors  of  the  stomach  and  pancreas,  etc.,  are  not  so  af- 
fected, unless  they  have  formed  adhesions  to  the  diaphragm. 

Pulsations  of  various  kinds  are  met  with  in  the  abdomen. 


might  occasion  would  be  vomiting,  dyspnoea,  and  slight  cyanosis — all 
disappearing  in  a  few  moments. 

*  In  children  the  liver  is  normally  large  in  proportion  to  the  size  of 
other  viscera,  and  occasions  a  considerable  degree  of  fulness  of  the  ab- 
domen, extending  from  the  lower  border  of  the  ribs  on  the  right  side  to 
the  level  of  the  umbilicus. 


46  MEDICAL   DIAGNOSIS. 

but   their   nature   will   be   more   conveniently   considered 
under  the  circulatory  system. 

Feristaltic  motions  of  the  intestines  may  be  observed  in 
persons  in  whom  the  abdominal  walls  are  abnormally  thin 
(as  in  ascites,  vide  anted)^  or  where  such  vermicular  move- 
ments are  unusually  energetic  (intestinal  obstruction,  irri- 
tation, etc.). 


CHAPTER  IV. 

Palpation  of  the  Abdomen. 

At  no  portion  of  the  body  is  the  skilful  application  of 
the  hand  of  more  essential  service  to  diagnosis  than  over 
the  abdomen.  By  carefully  pressing  with  the  hand  (which 
should  be  warmed)  at  various  points  with  a  kind  of  gentle 
kneading  motion,  we  obtain  by  the  sense  of  touch  informa- 
tion regarding,  \st,  the  condition  of  the  abdominal  wall; 
2^,  the  size,  form,  consistence,  and  mobility  of  certain  of 
the  abdominal  organs,  and  whether  any  tumor  be  present 
within  the  cavity  of  the  abdomen;  and  3</,  if  there  be  gen- 
eral tumefaction  of  the  abdomen,  whether  such  distension 
is  the  result  of  accumulation  of  gas  in  the  intestines 
(tympanites),  or  is  due  to  the  presence  of  serous  or  inflam- 
matory exudation;  and,  in  the  latter  case,  whether  such 
exudation  be  in  the  peritoneal  cavity  or  be  enclosed  in  a 
cyst  of  some  kind  or  another. 

The  position  of  the  patient  is  of  the  greatest  importance. 
He  must  lie  on  his  back,  with  head  and  neck  slightly  raised, 
and  with  the  knees  flexed  and  drawn  up  towards  the  abdo- 
men. In  most  cases  it  is  well  to  engage  the  patient  in  con- 
versation while  palpating  the  abdomen,  as  otherwise  the 
abdominal  muscles  are  usually  involuntarily  contracted, 
and  the  glottis  closed.  The  air  in  lungs,  retained  there  by 
the  closure  of  the  glottis,  supplies  the  necessary  resistance 
to  this  contraction  of  the  abdominal  muscles,  and  if  this 
resistance  be  removed  (as  is  best  done  by  forcing  the  patient 
to  open  his  glottis  in  speaking)  the  muscles  have  nothing 
to  contract  upon,  and  consequently  become  flaccid.  The 
relaxation  of  these  muscles  may  be  still  further  aided  by 
diverting  the  patient's  attention,  and  should  there  be  neces- 


PALPATION   OF  THE  ABDOMEN.  47 

sity  for  it,  the  exhibition  of  chloroform  will  allow  of  a  very- 
perfect  exploration  of  the  abdominal  cavity. 

Abdominal  Walls. — The  temperature  of  the  skin,  the 
amount  of  subcutaneous  fat,  the  presence  or  absence  of 
oedematous  or  ephysematous  swelling  of  the  subcutaneous 
cellular  tissue  (see  Chap.  I.)  are  readily  recognized  by  the 
palpating  hand,  and  require  no  special  mention  here.  Lo- 
calized swellings  of  the  abdominal  wall,  due  to  the  presence 
of  tumors,  of  inflammation  or  of  abscess,  may  be  mistaken 
for  more  serious  affection  of  the  abdominal  organs  them- 
selves. The  immobility  of  such  swellings,  their  position 
being  unaltered  by  the  respiratory  movements,  or  by  a 
change  in  the  position  of  the  patient,  will  generally  suffice 
to  distinguish  them.  In  reality,  the  physician  has  seldom 
any  difficulty  in  satisfying  himself  of  the  seat  of  the  swell- 
ing, whether  in  the  parietes,  or  in  the  cavity  of  the  abdo- 
men. In  difficult  cases,  such,  for  example,  as  when  a  deep- 
seated  abscess  over  the  liver  simulates  a  hepatic  abscess 
opening  outwards,  the  history  of  the  case,  and  the  other 
signs  and  symptoms,  suffice  as  a  general  rule  to  indicate 
the  real  seat  of  the  abscess. 

The  abdominal  muscles,  and  more  especially  the  "recti," 
present,  when  contracted,  certain  inequalities  in  thickness 
which  are  occasionally  mistaken  by  the  inexperienced  for 
abdominal  tumors. 

The  various  hernial  protrusions  which  are  found  in  the 
umbilical,  femoral,  and  inguinal  regions,  belong  more  es- 
pecially to  the  domain  o±  surgery. 

Peritoneal  Cavity. — Acute  general  peritonitis  gives  rise  to 
great  pain  and  tenderness  on  pressure  over  the  whole  sur- 
face of  the  abdomen.  In  chronic  peritonitis  a. characteristic 
doughy  resistance  is  usually  felt  over  the  affected  part,  ac- 
companied with  some  tenderness  on  pressure^^  Transuda- 
tion of  fluid  into  the  peritoneal  cavity  (ascites)  gives  rise 
to  a  feeling  of  fluctuation.  This  is  best  appreciated  by 
placing  the  hand  on  one  side  of  the  abdomen,  and  giving  a 
smart  tap  on  the  surface  at  a  point  diametrically  opposite. 
The  impulse  of  the  wave  so  formed  can  usually  be  clearly 
felt  when  it  reaches  the  opposite  wall.  If,  however,  the 
amount  of  fluid  be  small,  no  such  undulation  will  be  ob- 
served in  the  ordinary  position.  The  patient  may  then  be 
placed  on  his  elbows  and  knees,  when  the  fluid  will  gravi- 


48  MEDICAL  DIAGNOSIS. 

tate  to  the  anterior  part  of  the  sac,  and  fluctuation   can 
there  be  obtained. 

Friction  vibration  can  also  occasionally  be  felt  between 
two  roughened  peritoneal  surfaces.  It  may  be  synchronous 
with  the  respiratory  movements,  and  this  most  frequently 
if  the  visceral  and  parietal  layers  over  the  liver  and  spleen 
be  the  seat  of  the  roughness  (particularly  in  carcinoma  of 
the  liver).  Friction  vibration  can  also  be  induced  in  such 
cases  by  moving  the  peritoneal  surfaces  against  one  another, 
and  pressure  will  at  all  times  increase  the  strength  of  the 
friction. 

Liver. — In  the  healthy  adul^,  as  a  rule,  only  the  left  lobe 
of  the  liver  can  be  felt  by  the  palpating  hand,  giving  rise 
to  a  slight  feeling  of  resistance  in  the  epigastric  region. 
On  very  deep  inspiration,  however,  the  edge  of  the  right 
lobe  may  sometimes  be  made  to  project  so  far  beyond  the 
costal  margin  as  to  offer  appreciable  resistance  to  the  fin- 
gers. In  children  the  liver  is  of  such  size  as  to  be  readily 
examined  by  palpation. 

Either  as  a  result  of  enlargement  or  of  lowered  position 
(due,  for  example,  to  the  downward  pressure  of  a  pleural 
effusion),  the  liver  may  come  within  reach  of  the  palpat- 
ing hand,  and  then  we  have  to  examine  the  condition  of  its 
surface,  the  consistence  of  the  organ,  its  size  and  general 
shape. 

The  surface  of  the  liver  may  be  smooth  or  rough.  In 
amyloid  and  fatty  degeneration,  and  in  congestion,  the  sur- 
face ot  the  swollen  organ  is  smooth,  a  condition  which  is 
very  readily  recognized  by  palpation.  In  the  case  of  cirrho- 
sis, the  uneven  granular  surface  gives  rise  to  a  character- 
istic feeling  of  roughness  when  the  abdominal  wall  is  made 
to  glide  backwards  and  forwards  over  the  surface  of  the  liver. 
More  marked  irregularities  of  surface  are  found  in  carci- 
noma, the  distinct  nodules  of  which  can  be  felt,  and  occa- 
sionally the  umbilications  which  these  nodules  present. 

Tenderness  on  pressure  is  met  with  in  congestion  and  in 
all  inflammatory  affections  of  the  liver,  such  as  hepatic  ab- 
scess, cirrhosis,  catarrh  of  the  bile  ducts.  In  carcinoma  it 
is  often  a  very  marked  feature,  although  even  in  this  affec- 
tion it  may  be  absent.  There  is  usually  no  tenderness  in 
the  case  of  the  waxy  and  the  fatty  liven 

Consistence  of  the  liver  is  somewhat  increased  in  fatty  de- 
generation, still  more  so  in  congestion,  and  to  a  very  marked 


PALPATION   OF  THE   ABDOMEN.  49 

degree  in  waxy  disease,  when  the  lower  edge  may  assume 
an  almost  knife-like  sharpness.  The  presence  of  fluctuation 
will  usually  suffice  to  distinguish  a  hydatid  tumor  or  an 
abscess  from  a  solid  growth.* 

The  she  of  the  liver  varies  greatly.  In  some  cases,  as  in 
acute  yellow  atrophy,  the  organ  recedes  so  far  into  the  con- 
cavity of  the  diaphragm  as  to  be  out  of  reach  of  palpation. 
In  other  instances  (congestion,  waxy  degeneration,  etc.)  the 
lower  edge  may  be  found  as  low  as  the  symphysis  pubis. 
It  must  be  carefully  borne  in  mind  that  the  position  of  the 
lower  border  is  no  safe  guide  to  the  size  of  the  liver  unless 
it  be  taken  along  with  the  position  of  the  upper  margin  as 
ascertained  by  percussion. 

Ab7i07'7nalitie^  in  Shape. — The  practice  of  tight- lacing  not 
only  forces  the  liver  downwards,  but  also  frequently  so  com- 
presses the  hepatic  substance  as  to  give  rise  to  a  deep  fur- 
row marking  off  the  lower  portion  of  the  right  lobe.  This 
furrow  can  be  readily  detected  by  palpation.  Still  more 
obviously  is  the  shape  altered  by  the  presence  of  a  large 
tumor,  cancerous  or  hydatid,  growing  from  some  partic- 
ular part  of  the  organ.  It  is  most  important  to  remember 
that  hepatic  tumors  rise  and  fall  with  the  respiratory  move- 
ments, which  is  not  the  case  with  growths  in  the  stomach, 
omentum,  pancreas,  colon,  or  kidney,  unless  they  have 
become  adherent  to  the  liver. 

Occasionally  the  gall  bladder  maybe  felt  as  a  small  pear- 
shaped  tumor  projecting  from  beneath  the  lower  edge  of 
the  liver.  Pressure,  by  emptying  it  of  bile,  may  cause  it  to 
disappear,  and  in  rare  cases  the  presence  of  gall-stones  in 
the  bladder  may  be  ascertained  by  palpation. 

Spleen. — In  the  normal  condition  the  spleen  cannot  be 
felt,  and  this  is  partly  due  to  its  deep-seated  position,  and 
partly  to  the  fact  that  the  splenic  tissue  is  too  soft  to  offer 
resistance  to  the  palpating  fingers.  When,  however,  it  be- 
comes so  enlarged  as  to  reach  the  extremity  of  the  eleventh 
rib,  or  to  pass  beyond  it,  then  the  spleen  can  be  readily 
recognized.  Increase  in  size  of  the  spleen  takes  place  in 
numerous    diseases,  such    as  leucocythaemia,  amyloid   dis- 

*When  a  hydatid  tumor  lying  near  the  surface  of  the  liver  is  percussed, 
a  peculiar  and  very  characteristic  tremor  (hydatid  fremitus)  may  be  felt 
over  it,  due  to  the  reflection,  from  side  to  side  oi  the  sac,  of  the  undula- 
tions into  which  the  fluid  has  been  thrown. 


50  MEDICAL  DIAGNOSIS. 

ease,  recent  syphilis,  intermittent  fever,  typhus,  enteric,  and 
scarlet  fevers,  etc.;  and -in  addition,  all  diseases  which  pro- 
duce obstruction  to  the  portal  circulation,  directly  or  indi- 
rectly (such  as  cirrhosis  of  the  liver  and  heart  disease), 
cause  splenic  congestion,  and,  consequently,  enlargement 
of  that  organ. 

When  the  spleen  is  but  slightly  enlarged  it  can  be  best 
felt  by  tilting  it  upwards  from  the  lumbar  region  on  to  the 
palpating  hand.  A  feeling  of  increased  resistance  may  thus 
be  appreciated,  although  the  limits  of  the  organ  may  not 
be  felt  with  any  distinctness. 

As  the  organ  increases  in  size  it  projects  from  beneath 
the  margins  of  the  ribs  towards  the  umbilicus,  and  rises 
and  falls  to  a  slight  extent  with  the  respiratory  movements. 
The  enlargement  is  proportionately  the  same  in  all  diame- 
ters, and  so  the  spleen  retains  its  original  shape.  The 
splenic  notch  is  readily  felt,  and  is  important  as  a  certain 
indication  that  the  tumor  with  which  we  have  to  deal  is 
splenic.  In  leucocythaemia  the  spleen  may  attain  an  enor- 
mous size,  and  fill  up  the  greater  part  of  the  abdominal 
cavity.  Except  in  very  rare  cases  (hydatid  disease  and 
carcinoma  of  the  spleen)  the  surface  of  the  swollen  organ 
is  smooth,  and  there  is  rarely  any  tenderness  on  pressure. 

The  consistency  of  the  spleen  is  greatly  increased  ^  in 
amyloid  disease  and  in  leucocythaemia.  In  congestive 
enlargement  it  is  not  so  resistant,  and  in  acute  diseases  the 
tumefied  gland  is  of  a  very  soft  consistence.  During  the 
exacerbations  of  intermittent  fever  the  spleen  undergoes 
perceptible  enlargement,  while  in  cases  of  splenic  conges- 
tion from  portal  obstruction,  loss  of  blood  from  the  stom- 
ach or  intestines  causes  diminution  in  its  size. 

Pancreas. — Tumors  of  the  head  of  the  pancreas  are 
rarely  met  with,  and  are  difficult  of  diagnosis,  owing  to 
the  way  in  which  the  gland  is  covered  by  the  coils  of 
the  intestines,  and  to  some  extent  by  the  lower  edge  of  the 
liver.  Hardness  in  such  cases  can  usually  be  felt  to  the 
right  of  the  middle  line  above  the  level  of  the  umbilicus. 
It  is  deeply  seated,  not  freely  movable,  and  unaffected  by 
the  respiratory  movements.  The  disease  (which  is  almost 
invariably  carcinoma)  is  seldom  limited  to  the  pancreas, 
but  attacks  the  retro-peritoneal  lymphatic  glands  and  other 
neighboring  parts. 

Stomach  and  Intestines. — Tumors  of  the  stomach   (usu- 


PALPATION  OF  THE  ABDOMEN.  5 1 

ally  carcinomatous)  are  most  common  at  the  pylorus. 
They  are  readily  felt  as  irregular,  nodulated  masses  in  the 
umbilical  region,  freely  movable  for  the  most  part,  and  but 
little  affected  in  position  by  the  rise  and  fall  of  the  dia- 
phragm. When  the  greater  curvature  is  the  part  affected, 
the  tumour  mass  is  found  somewhat  lower  down,  and  to 
the  left.  Tumors  of  the  lesser  curvature  and  cardiac  end 
of  the  stomach  afe  rarely  felt  during  life,  as  they  lie  so 
deeply  in  the  concavity  of  the  diaphragm. 

Pressure  over  the  stomach  occasions  pain  in  many  dis- 
eased conditions  of  that  viscus.  It  is  most  circumscribed  in 
cases  of  gastric  ulcer,  and  is  often  of  very  great  severity. 

In  the  intestines  the  retention  of  faeces,  chiefly  in  the 
large  intestine,  may  give  rise  to  localized  swelling  at  vari- 
ous points.  These  nodular  masses  are  of  a  doughy  consis- 
tency, and  to  a  large  extent  disappear  after  purgation. 
Catarrhal  and  inflammatory  conditions  of  the  colon  are  apt 
to  give  rise  to  inflapnmation  in  the  neighboring  tissues, 
resulting  in  a  swelling  which  is  usually  ill-defined,  doughy, 
hard,  and  very  tender  on  pressure.  Such  inflammatory 
processes  usually  take  place  round  the  caecum  (perityphli- 
tis). Cancerous  masses  may  occasionally  be  felt  at  various 
parts  of  the  colon:  the  caecum  and  sigmoid  flexure  being 
most  commonly  the  seat  of  the  disease.  Peristaltic  move- 
ments of  the  intestines  are  occasionally  to  be  felt  when  the 
abdominal  walls  are  thin  or  the  movements  very  energetic, 
as  in  stenosis  of  the  bowel. 

Tumors  of  the  07nentum  are  rare.  They  are  of  very  vari- 
ous nature:  cancerous,  tubercular,  hydatid,  etc.,  and  when 
developed  are  readily  felt  through  the  abdominal  wall. 
When  affected  v/ith  carcinomatous  disease  the  omentum 
becomes  thickened  and  retracted,  and  its  lower  hardened 
edge  may  occasionally  be  felt  crossing  the  abdominal  cavity. 

The  Mesenteric  Glands  are  frequently  the  seat  of  tumors. 
They  may  be  simply  enlarged,  along  with  other  similar 
glands  throughout  the  body,  or  they  may  be  affected  with 
cancerous,  tubercular,  or  other  deposits.  They  are 
smooth,  hard,  movable  tumors  of  regular  form.  Occa- 
sionally they  become  fused  together,  along  with  other 
neighboring  structures  (loops  of  snjall  intestines,  retro- 
peritoneal glands,  etc.),  into  masses  of  considerable  size, 
which,  overlying  the  aorta,  may  have  imparted  to  them  a 
pulsatile  movement. 


52  MEDICAL  DIAGNOSIS. 

The  Kidneys  are  not,  in  their  normal  condition,  within 
the  range  of  palpation;  but  when  they  leave  their  posi- 
tion, or  when  they  increase  greath''  in  size,  they  may  be  felt. 
A  floating  kidney — that  is,  one  the  attachments  of  which 
are  so  loose  as  to  allow  of  its  moving  more  or  less  freely 
through  the  abdominal  cavity — is  recognized  by  its  possess- 
ing the  size  and  the  characteristic  renal  shape,  as  well  as 
by  its  great  mobility,  and  by  the  presence  of  the  pulsating 
renal  artery,  which  may  sometimes  be  felt  entering  at  the 
hilus.  The  diagnosis  is  rendered  more  certain  by  the  aid 
of   percussion,   as  will    be    noticed  under  that   head   {luide 

p-  58). 

Enlargement  of  the  kidney  occurs  in  hydronephrosis, 
echinococcus,  carcinoma,  etc.,  and  the  tumor  is  smooth  or 
nodular  according  to  its  nature.  It  is  recognized  by  its 
position  and  relations,  its  immobility,  and  its  cylindrical 
shape  from  above,  downwards.  Inflammatory  thickening 
round  the  kidney  and  perinephritic  abscess  may  also  be 
recognized  by  palpation. 

The  urinaj-y  bladder,  when  distended,  forms  a  pyriform 
tumor  above  the  pubes,  and  may  reach  the  level  of  the 
umbilicus,  or  even,  in  extreme  cases,  to  a  still  higher 
point. 

Ovaria7i  tumors  in  most  cases  are  cystic,  and  may  be  so 
large  as  to  distend  the  whole  abdomen.  When  small  in 
size  they  are  usually  on  one  side  only,  and  gradually  cross 
the  middle  line  to  assume  an  apparently  central  position. 
Fluctuation  is  generally  easily  made  out.  The  characteris- 
tics of  such  growths,  as  well  as  of  tumors  of  the  uterus, 
physiological  and  pathological,  will  be  considered  in  con- 
nection with  the  reproductive  system. 

Aneurism  of  the  abdo7ninal  aorta  may  affect  that  vessel  in 
any  part  of  its  course.  If  it  lie  very  deep  in  the  concavity 
of  the  diaphragm,  it  may  not  be  capable  of  being  felt  with 
any  distinctness,  but  where  it  can  be  reached  a  pulsating 
tumor  is  readily  recognized.  The  pulsation  must  be  dis- 
tinguished from  that  produced  by  a  tumor  lying  on  the 
vessel,  which  is  to  be  done  by  noting  its  true  expansile 
character  when  compressed  laterally  between  the  fingers. 
Aneurisms  of  the  main  branches  of  the  abdominal  aorta 
also  occasionally  occur. 


PERCUSSION   OF   THE  ABDOMEN.  53 

CHAPTER  V. 

Percussion  of  the  Abdomen. 

The  theory  of  percussion  will  be  considered  hereafter, 
and  need  not  detain  us  here.  Its  use  in  connection  with 
the  abdomen  is  to  define  the  outline  of  organs  which  it  is 
not  possible  to  reach  by  means  of  palpation.  As  a  rule  it 
is  best  to  use  the  forefinger  of  the  left  hand  as  a  plexi- 
meter,  laying  it  upon  the  surface  of  the  abdomen,  and 
eliciting  a  note  by  striking  with  one  or  more  fingers  of  the 
right  hand.  The  change  of  note  as  one  passes  off  such  a 
solid  organ  as  the  liver  on  to  air-containing  viscera,  is 
usually  sufficiently  obvious. 

Percussion  gives  information  concerning — 

1.  The  Condition  of  the  Peritoneal  Sac. 

2.  The  Outline  of  the  Liver. 

3.  The  Outline  of  the  Spleen. 

4.  The  Outline  of  the  Kidneys. 

5.  The  Condition  of  the  Stomach  and  Intestines. 

Condition  of  the  Peritoneal  Sac. — When  transudation  of 
fluid  takes  place  into  the  peritoneal  cavity,  it  does  not  in 
the  first  instance  affect  the  percussion  note  over  the  surface 
of  the  abdomen,  since  the  small  quantity  of  serum,  which 
at  first  collects,  gravitates  towards  the  lowest  portion  of  the 
sac;  and  whether  this  point  lie  in  the  pelvis  or  towards  the 
spinal  column  (determined  by  the  position  of  the  patient, 
erect  or  supine),  the  collection  is  too  fai-  removed  from  the 
surfaces  ordinarily  subjected  to  percussion  to  allow  of  its 
influencing  the  note  obtained. 

As  the  quantity  increases  it  gradually  makes  its  presence 
manifest,  causing  a  dull  note  to  be  heard  on  percussion 
over  the  lower  parts  of  the  peritoneal  cavity.  With  further 
increase  in  the  quantity  of  fluid,  the  dulness  extends  its 
area,  until  in  extreme  cases  where  the  sac  is  greatly  dis- 
tended with  transudation  and  the  bowels  compressed,  the 
note  over  the  whole  surface  of  the  abdomen  becomes  abso- 
lutely dull.  In  cases  of  medium  severity,  when  the  patient 
lies  on  his  back,  the  fluid  gravitates  towards  the  lumbar 
regions,  and  the  intestines  float  on  its  surface,  so  that  the 
percussion  note  over  the  anterior  surface  of  the  abdomen 


54  MEDICAL  DIAGNOSIS. 

is  clear  and  tympanitic,  expressing  the  presence  of  large 
air  cavities  beneath  (bowels),  while  on  either  side,  as  we 
pass  towards  the  lateral  and  posterior  regions,  there  is  dul- 
ness  corresponding  to  the  position  of  the  ascitic  fluid.  If 
the  patient  lie  on  his  left  side  the  right  side  will  be  the 
point  towards  which  the  air-containing  intestines  will  float, 
whereas  the  fluid  in  the  peritoneal  cavity  will  gravitate  to- 
wards the  left.  The  change  in  the  percussion  note  thus 
caused  by  alteration  in  the  position  of  the  patient  is  an  in- 
dication of  the  presence  of  free  fluid  in  the  peritoneum, 
and  is  the  more  important  seeing  that  it  does  not  occur  in 
the  case  of  ovarian  dropsy. 

Ascites  is  either  the  result  of  increase  in  the  blood  pres- 
sure within  the  portal  vein  due  to  cirrhosis  of  the  liver, 
tuberculosis  of  the  peritoneum,  etc.,  or  is  merely  a  part  of 
the  general  dropsical  condition  caused  by  cardiac  or  renal 
disease. 

Percussion  of  the  Liver. — A  considerable  portion  of  the 
anterior  and  upper  surface  of  the  liver  lies  in  contact  with 
the  anterior  wall  of  the  abdomen,  and  consequently  over 
this  area  the  percussion  note  is  more  or  less  absolutely 
dull  expressing  the  presence  of  a  solid  organ  underneath. 
This  area  is  spoken  of  as  the  absolute  hepatic  dubiess. 

Above  this  the  liver  recedes  from  the  chest-wall  and  be- 
comes separated  therefrom  by  a  layer  of  lung  of  gradually- 
increasing  depth.  In  percussion  from  above  downwards  in 
the  right  parasternal  line,  the  level  at  which  the  percussion 
note  indicates  that  the  subjacent  air  space  is  being  en- 
croached upon  and  rendered  shallower,  corresponds  (in  the 
normal  condition)  to  the  highest  point  to  which  the  liver 
reaches  under  the  diaphragm,  and  at  this  level  the  deep  or 
relative  hepatic  dulness  commences. 

The  tympanitic  resonance  of  the  neighboring  abdominal 
organs  which  contain  air  enables  us  to  mark  out  with  con- 
siderable ease  the  lower  border  of  hepatic  dulness.  The 
thinness  of  the  lower  edge  of  the  liver  necessitates  that  per- 
cussion should  be  made  very  lightly  in  order  that  we  may 
avoid,  as  much  as  possible,  the  transmission  of  the  vibra- 
tions to  parts  in  the  vicinity.  It  is  best  practised,  in  this 
particular  instance,  by  tapping  very  gently  with  the  fore- 
finger on  an  ivory  pleximeter. 

The  lower  border  of  the  liver  begins  at  the  left,  close  to  the 
apex  of  the  heart,  and  passes  diagonally  downwards  and  to- 


PERCUSSION   OF  THE  ABDOMEN.  55 

wards  the  right,  crossing  the  middle  line  at  a  point  mid- 
way between  the  ensiform  cartilage  and  the  umbilicus,  and 
joining  the  margin  of  the  ribs  at  an  acute  angle  in  the 
mammary  line.  From  this  point  backwards  to  the  axillary 
line  the  lower  border  corresponds  pretty  closely  with  the 
margin  of  the  ribs.  In  many  cases  careful  percussion  will 
detect  the  presence  of  the  gall-bladder,  as  a  small  rounded 
tumor  projecting  downwards  from  the  edge  of  the  liver. 

The  upper  border  of  absolute  hepatic  dulness  corresponds  to 
the  lower  edge  of  the  right  lung,  except  in  regard  to  the 
left  lobe,  where  it  passes  imperceptibly  into  the  cardiac 
dulness.  At  the  right  border  of  the  sternum  it  lies  at  the 
level  of  the  6th  rib;  in  the  mammillary  line  it  corresponds 
to  the  upper  border  of  the  7th  rib;  and  in  the  axillary  and 
scapular  lines  it  reaches  respectively  the  8th  and  9th  ribs. 

The  upper  limit  of  the  deep  or  relative  hepatic  dulness  lies 
about  three  inches  above  the  absolute  dulness;  In  the 
mammillary  line  the  percussion  note  can  usually  be  noticed 
to  become  dull  about  the  4th  intercostal  space,  or  5th  rib. 

The  movements  of  respiration  change  the  position  of  the 
liver.  Deep  inspiration  depresses  the  lower  edge  consider- 
ably, while  full  expiration  permits  of  a  corresponding  ele- 
vation. But  in  addition  to  such  alterations  in  the  level  at 
which  the  lower  border  of  the  liver  stands,  the  respiratory 
movements  affect  the  position  of  the  upper  border  of  the 
absolute  dulness  to  a  much  greater  extent.  This  latter 
alteration  in  hepatic  dulness  does  not  express  so  much  an 
alteration  in  the  position  of  the  liver,  as  the  rise  and  fall  of 
the  lower  border  of  the  right  lung,  and  the  extent  of  the 
complimentary  pleural  space  occupied  by  pulmonic  tissue. 

Changes  in  the  position  of  the  body  also  cause  slight 
differences  in  the  position  of  the  liver,  the  organ  gravitating 
towards  the  most  dependent  side. 

The  hepatic  dulness  may  be  greatly  altered  without  any 
actual  change  in  the  size  of  the  liver.  Thus  the  colon,  dis- 
tended by  air  or  by  a  coil  of  the  small  intestine,  may  be 
forced  upwards  between  the  surface  of  the  liver  and  the 
abdominal  parietes,  thus  preventing  the  true  lower  bor- 
der from  being  found  by  percussion,  and  leading  to  an 
apparent  diminution  in  the  size  of  the  liver.  In  pul- 
monary emphysema  the  right  lung  extends  lower  down 
than  normally,  and  the  upper  border  of  absolute  liver  dul- 
ness is  thus  depressed.  Again,  the  liver  may  be  elevated 
abnormally  within  the  concavity  of  the  diaphragm,  by  reason 


56  MEDICAL  DIAGNOSIS. 

of  increased  intra-abdominal  pressure;  a  greater  proportion 
of  the  organ  will  be  thus  overlapped  by  lung,  and  the  abso- 
lute dulness  diminished.  If  the  two  last  conditions  co- 
exist, all  trace  of  absolute  hepatic  dulness  may  fail,  and 
this  may  occur  when  the  liver  is  of  normal  size. 

From  all  this  it  follows  that  the  extent  of  the  absolute 
hepatic  dulness  is  no  safe  guide  to  the  size  of  this  organ, 
and  in  all  cases  it  is  best  to  measure  from  the  upper  level 
of  the  deep  or  relative  dulness  to  the  lower  border  of  the 
liver.  Unfortunately,  in  some  cases  such  measurements 
cannot  be  accurately  made  (right  pleural  effusion,  pro- 
nounced ascites,  etc.),  but  when  percussion  can  determine 
the  deep  dulness,  the  position  of  the  lower  border  can  in 
such  cases  usually  be  ascertained  by  palpation. 

Displacement  of  the  liver  takes  place  more  frequently  down- 
wards than  upwards.  The  causes  of  displacement  doivnwards 
are — (i)  Emphysema  of  the  lungs,  when  both  hepatic  lobes 
are  equally  depressed;  (2)  Pleuritic  effusion  on  the  right 
side,  which  causes  depression  of  the  right  lobe  of  the  liver, 
with  perhaps  slight  elevation  of  the  left  lobe;  (3)  Right 
pneumothorax  producing  the  same  conditions.  To  these 
maybe  added,  as  much  rarer  causes  of  downward  displace- 
ment, various  tumors  of  the  mediastinum  and  of  the  dia- 
phragm, and  encapsuled  peritoneal  effusions  between  the 
diaphragm  and  the  upper  surface  of  the  liver.  The  left 
lobe  of  the  liver  may  be  slightly  depressed  by  large  peri- 
cardial effusions,  and  by  effusion  of  liquid  or  gas  into  the 
left  pleural  cavity. 

Displacement  iLpivards  occurs  less  frequently,  and  to  a  less 
extent,  than  depression.  It  is  occasioned  by  any  condition 
which  produces  an  increased  pressure  in  the  abdominal 
cavity — ascites,  meteorism^  ovarian  cysts,  etc. — and  possi- 
bly also  by  cirrhosis  of  the  right  lung. 

Hepatic  JEnlargement. — The  increase  in  size  of  the  liver 
may  be  very  marked.  It  may  in  rare  cases  rise  as  high  as 
the  2d  rib  (Gerhardt),  while  its  lower  edge  may  reach  to  a 
point  close  to  the  symphysis  pubis.  The  chief  causes  of 
great  enlargement  of  this  organ  are  hydatid  tumors,  carci- 
noma, and  waxy  disease.  It  is  found  to  a  less  degree  in 
hepatic  congestion  (as  in  mitral  disease),  occlusion  of  the 
bile  ducts,  fatty  degeneration,  and  in  certain  cases  of  cir- 
rhosis. (The  alteration  in  the  shape  of  the  liver,  caused  by 
the  practice  of  "  tight-lacing,"  may  simulate  actual  enlarge- 
ment.) 


PERCUSSION   OF   THE   ABDOMEN.  57 

Diminution  in  the  size  of  the  liver  occurs  in  the  later  stage 
of  cirrhosis,  and  in  acute  yellow  atrophy  of  the  liver.  The 
organ,  as  it  becomes  smaller,  leaves  the  surface  of  the  ab- 
domen and  retreats  into  the  concavity  of  the  diaphragm. 
Its  place  is  occupied  by  small  and  large  intestines,  and,  in 
consequence,  all  trace  of  hepatic  dulness  may  disappear. 
This  extreme  diminution  is  met  with  in  the  latter  disease, 
whilst  in  cirrhosis,  when  the  liver  is  much  contracted,  the 
percussion  of  the  lower  border  is  prevented  by  the  almost 
invariable  presence  of  ascites  at  that  stage. 

Percussion  of  the  Spleen. — Placed  obliquely  in  the  cavity 
of  the  abdomen,  the  spleen  lies  with  its  upper  and  poste- 
rior extremity  opposite  the  tenth  dorsal  vertebra  in  the 
concavity  of  the  diaphragm  and  somewhat  overlapped  by 
the  left  lung.  From  this  point  the  gland  passes  downwards 
and  forwards  to  terminate  slightly  behind  the  extremity  of 
the  eleventh  rib.  Its  upper  and  anterior  border  runs  paral- 
lel with  the  ninth  rib,  while  the  posterior  and  lower  border 
follows  pretty  closely  the  eleventh  rib. 

The  percussion  of  the  spleen  is  peculiarly  important, 
because  when  the  organ  is  but  slightly  enlarged,  it  is  prac- 
tically inaccessible  to  palpation.  In  consequence  of  the 
nearness  of  large  air-cavities  in  the  stomach  and  colon,  it  is 
necessary  to  percuss  very  lightly,  in  order  to  obtain  the 
splenic  dulness,  and  not  allow  the  note  to  become  obscured 
by  reason  of  the  tympanitic  resonance  of  these  organs. 

The  spleen  is  of  variable  size,  and  as  age  advances  it 
atrophies  so  that  a  small  area  of  dulness  may  be  met  with 
under  physiological  conditions. 

Respiratory  movements  affect  the  position  of  the  splenic 
dulness,  deep  inspiration  depressing  it  and  diminishing  its 
size.  When  the  patient  lies  on  the  right  side  the  spleen 
tends  to  gravitate  towards  that  direction,  and  the  splenic 
dulness  diminishes  or  disappears.  When  the  spleen  is  not 
greatly  enlarged,  it  is  best  to  percuss  it  when  the  patient  is 
in  the  erect  position,  with  the  left  arm  removed  from  the 
the  side. 

The  condition  of  the  stomach  has  an  important  influence 
on  the  percussion  of  the  spleen.  If  the  fundus  is  greatly 
distended  with  food,  it  occasions  a  dull  note  on  percussion 
in  the  neighborhood  of  the  spleen  in  such  a  way  as  alto- 
gether to  prevent  the  differentiation  of  the  splenic  dulness. 
On  the  other  hand,  if  the  stomach  be  distended  with  gas  to 


58  MEDICAL  DIAGNOSIS. 

a  marked  degree,  it  becomes  difficult  to  determine  with 
any  exactness  the  limits  of  the  splenic  dulness,  because  of 
the  tympanitic  resonance  of  the  gastric  cavity,  which  even 
a  very  light  stroke  can  hardly  fail  to  produce. 

Conditions  similar  to  those  which  cause  upward  displace- 
ment of  the  liver  (p.  56)  force  the  spleen  in  the  same  direc- 
tion under  the  lower  margin  of  the  left  lung;  and  in  this 
case,  as  well  as  when  the  spleen  is  overlapped  by  emphyse- 
matous pulmonary  tissue,  all  traces  of  splenic  dulness  dis- 
appear. 

The  presence  of  ascitic  fluid  round  the  spleen  will  pre- 
vent its  limits  from  being  determined  by  percussion,  and 
meteoric  distension  of  the  intestine  with  gas  will  cause  a 
diminution  in  the  size  of  the  splenic  dulness. 

In  pleuritic  effusion  and  pneumothorax  on  the  left  side, 
as  well  as  in  pulmonary  emphysema,  the  spleen  is  depressed, 
but  in  none  of  these  conditions  is  it  possible  to  define  its 
limits  by  percussion. 

Enlargement  of  the  spleen  is  readily  made  out  by  means 
of  percussion;  but  this  method  does  not  give  any  clue 
to  the  cause  of  the  tumefaction,  as  in  all  cases  the  gland 
enlarges  uniformly  in  all  directions.  When  it  passes 
beyond  the  borders  of  the  ribs,  it  is  best  recognized  by 
means  of  palpation.  The  various  forms  of  splenic  tumor 
have  been  already  referred  to  and  need  not  now  be  recapit- 
ulated. 

Percussion  of  the  Kidneys. — It  is  only  in  the  rarest  of 
cases  that  such  a  method  of  examination  need  be  resorted 
to  to  aid  in  forming  a  diagnosis,  and  this  because  (i)  the 
most  frequently  occuring  renal  diseases  are  not  accompan- 
ied by  so  great  an  amount  of  alteration  in  the  dimen- 
sions of  these  organs  as  to  be  appreciable  by  percussion; 
and  (2)  those  cases  of  renal  tumors  where  the  tumor 
mass  might  be  thus  recognized  are  capable  of  far  earlier 
and  much  more  thorough  investigation  by  palpation.  Renal 
percussion  may  in  fact  be  regarded  as  of  no  importance, 
except  perhaps  in  the  single  instance  of  the  diagnosis  of 
floating  kidney,  where  the  absence  of  the  normal  area  of 
renal  dulness  on  one  side  might  confirm  the  opinion.  But 
as  undoubtedly  in  many  cases  the  percussion  of  the  kidneys 
can  be  carried  out,  the  subject  must  not  be  entirely  ignored 
here. 

The  percussion  stroke  must  be  very  firm,  and  is  best 


TERCUSSION   OF   THE   ABDOiMEN.  59 


xiS 


given  by  means  of  a  hammer  and  an  ivory  pleximeter.  In 
persons  in  whom  there  is  great  development  of  the  subcu- 
taneous adipose  tissue,  the  kidneys  cannot  be  percussed. 

The  upper  border  of  the  renal  dulness  cannot  be  defined, 
as  it  passes  imperceptibly  into  that  of  the  liver  or  spleen,  and 
the  internal  border  lying  next  the  spinal  column  is  also  in- 
capable of  definition.  It  is  then  chiefly  the  outer  border, 
lying  in  the  lumbar  region,  parallel  to  and  about  three 
linger-breadths  distance  from  the  spinal  column,  that  can 
be  marked  out,  while  in  some  few  cases  the  position  of  the 
lower  border,  close  to  the  crest  of  the  ilium,  can  also  be 
ascertained. 

The  patient  must  be  laid  prone,  the  anterior  surface  of 
the  abdomen  being  supported  on  cushions.  The  lower 
edges  of  the  hepatic  and  splenic  dulness  in  the  scapular 
line  on  either  side  must  first  be  marked  out.  Immediately 
oelow  these  levels  the  tympanitic  note  of  the  colon  or  of 
the  stomach  can  be  heard.  If  now  we  percuss  inwards  on 
either  side  towards  the  vertebral  column,  the  renal  dulness 
will  be  reached  at  the  distance  already  indicated.  The 
length  of  the  renal  dulness  is  usually  from  three  to  four 
inches,  and  occasionally,  as  I  have  already  said,  the  lower 
border  may  also  be  defined  by  percussion. 

[The  urinary  bladder  does  not  enter  the  abdomen  unless 
distended,  and  then  it  can  readily  be  percussed  out  as  a 
pear-shaped  tumor  l5"ing  in  the  middle  line,  and  giving  a 
dull  note.] 

Percussion  of  the  Stomach. — When  the  stomach  is  filled 
with  food  it  is  impossible  to  define  its  boundaries  in  any 
way  by  means  of  percussion;  but  when  the  cavity  of  the 
viscus  is  moderately  distended  with  air  it  gives  on  per- 
cussion a  tympanitic  note  of  so  low  a  pitch  and  of  so  long 
duration  that  it  is  readily  distinguishable  from  the  tym- 
panitic notes  obtained  from  the  neighboring  hollow  vis- 
cera, and  this  by  reason  of  the  greater  size  of  the  air-cavity. 
Should,  however,  the  distention  of  the  stomach  with  gas 
increase  beyond  a  certain  point,  the  walls  are  also  thrown 
into  vibration,  and  a  metallic  ring  results,  which  renders 
the  definition  of  the  gastric  outlines  more  difficult."^ 

The  position  of  the  stomach  is  such  that  its  border  can 

*  I  have  already  alluded  to  the  method  of  artificially  distending  the 
stomach  with  gas  for  purposes  of  diagnosis. 


6o  MEDICAL  DIAGNOSIS. 

be  satisfactorily  defined  only  in  one  direction,  /.<?.,  in  the 
line  of  the  greater  curvature;  but  the  ascertaining  of  the 
position  of  this  border  is  sufficient  to  enable  us  to  say 
whether  the  viscus  be  enlarged  or  not. 

It  is  best,  first  of  all,  to  mark  out  the  borders  of  the  vari- 
ous other  organs  which  surround  the  stomach,  namely,  the 
liver  and  spleen,  as  well  as  the  position  of  the  diaphragm. 
It  is  then  found  that  the  deep-pitched  note  of  the  stomach 
extends  from  the  middle  line  to  the  left  hypochondrium, 
neither  passing  to  the  right  of  the  middle  line  nor  below 
the  level  of  the  umbilicus.  If  either  of  those  limits  be 
overstepped  at  any  point,  the  stomach  is  enlarged. 

Over  the  intestines  the  percussion  note  is  normally  tym- 
panitic, but  is  higher  in  pitch  than  over  the  stomach. 

When  the  bowels  become  distended  with  liquid  or  solid 
contents  this  note  ceases  to  be  heard. 

Great  distention  with  gas  allows  the  walls  of  the  intes- 
tines to  pass  also  into  vibration,  thereby  producing  a  metal- 
lic note. 

Auscultation  of  the  Abdominal  Organs. — Auscultation  of 
the  abdominal  organs  is  rarely  of  value  as  an  aid  to  diag- 
nosis, if  we  except  the  auscultation  of  the  uterus  in  preg- 
nancy, which  does  not  concern  us  here,  and  aneurisms  of 
the  abdominal  aorta  and  its  branches,  which  will  be  better 
considered  in  connection  with  the  circulatory  system. 


CHAPTER  VI. 

HEMOPOIETIC  System. 


Lymphatic  Vessels — Inflammation  — Narrowing  and  Dilatation — Rup- 
ture. 

Lymphatic  Glands — Inflammatory  Enlargement — Scrofula — Syphilis — 
Cancer — Adenia — Leucocythaemia — Plague — Glanders  and  Farcy. 

Ductless  Glands — Spleen — Thyroid — Thymus. 

Examination  of  the  Blood — Microscopic  Examination — Enumeration 
of  Corpuscles — Estimation  of  Haemoglobin. 

Under  this  heading  we  have  to  consider  the  lymphatic 
system,  the  various  ductless  glands  (spleen,  thyroid,  etc.), 
and  the  microscopic  characters  of  the  blood. 


HiEMOPOIETIC   SYSTEM.  6l 

I.  The  Lymphatic  Vessels,  as  well  their  capillary  net- 
work as  their  larger  trunks,  and  the  thoracic  duct  itself, 
undergo  various  pathological  changes,  which,  although  in 
great  measure  belonging  to  the  domain  of  surgery,  come 
frequently  under  the  observation  of  the  physician.  For 
convenience  of  description  the  following  order  will  be  here 
followed: 

(a.)  Infla7nmation  of  the  lymphatics  (lymphangitis)  de- 
pends almost  invariably  upon  the  absorption  of  some  irri- 
tating (usually  septic)  material  from  the  tissues.  It  some- 
times follows  some  slight  wound  or  sting,  but  often  results 
from  gonorrhoeal,  syphilitic,  cancerous,  or  erysipelatous  irri- 
tation. The  superficial  lymphatics  show  themselves  as 
pale  red  lines  passing  up  towards  the  glands,  and  the  larger 
vessels  may  be  felt  as  hard  and  knotted  cords,  and  pressure 
over  them  is  painful.  There  is  usually  some  swelling  of 
the  surrounding  tissues. 

.(^.)  Narrowing  and  Dilatation. — Narrowing  and  obstruc- 
tion of  the  lymphatic  vessels  may  arise  from  the  pressure 
of  neighboring  tumors,  from  inflammation,  thrombosis,  etc. 
Dilatation  (Lymphangiectasis)  is  commonl)'-  the  result  of 
this  narrowing,  or  obliteration,  but  it  may  arise  also  from 
disease  of  the  lymphatic  glands  preventing  the  flow  of 
lymph.  Sometimes  this  dilatation  exists  without  giving 
rise  to  any  symptom,  but  when  the  lymphatics  affected  are 
superficial,  they  may  be  readily  felt.  This  occurs  most 
frequently  on  the  inner  sides  of  thighs,  on  the  scrotum, 
penis,  and  lower  surface  of  the  abdomen.  Nodular  vesi- 
cles like  sago  grains,  may  then  be  felt  lying  under  the 
skin,  which  sometimes  spontaneously  rupture,  discharging 
lymph.  They  are  to  be  distinguished  from  varicose  veins 
by  their  position,  form,  and  color.  Sometimes  the  enlarged 
lymphatic  trunks  take  the  form  of  a  tumor  (lymphangioma), 
usually  in  the  tongue,  cheek,  or  neck. 

The  Thoracic  Duct  itself  is  sometimes  narrowed,  or  oc- 
cluded, most  commonly  as  the  result  of  the  pressure  of 
thoracic  tumors  (aneurisms,  cancerous  and  tubercular  dis- 
ease of  the  mediastinal  glands),  and  sometimes,  perhaps, 
from  inflammation  of  its  coats,  or  thrombosis.  This  ob- 
struction is  followed  by  dilatation  of  the  duct  (which  may 
also  arise  from  stasis  in  the  large  veins  at  the  root  of  the 
neck,  the  result  of  heart  disease),  and  this  dilatation,  espe- 
cially if  it  take  place  slowly,  may  give  rise  to  no  symptom. 
Very  often,  however,  it  is  followed  by  marked  wasting  and 


62  MEDICAL  DIAGNOSIS. 

anaemia,  and  sometimes  by  ascites,  and  even  hydrothorax, 
the  fluid  poured  out  in  the  pleural  or  peritoneal  cavity  re- 
sembling chyle. 

(c.)  Rupture. — The  discharge  of  lymph  (lymphorrhagia) 
follows  every  wound,  and  only  becomes  important  when  it 
flows  from  a  large  trunk,  a  condition  which  may  be  caused 
by  wound,  by  ulceration,  or  by  ruptu/e  following  previous 
dilatation.  Its  diagnosis  can  present  no  difficulty  when  the 
effusion  of  lymph  takes  place  externally.  Rupture  is  most 
frequent  in  the  inguinal  region.  The  lacteals  sometimes 
rupture  (the  result  of  congestion  from  the  pressure  of  a  tu- 
mor), discharging  their  chyle  into  the  peritoneal  cavity, 
and  usually  giving  rise  to  no  symptom.  Several  cases  are 
on  record  of  rupture  of  the  thoracic  duct,  caused  by  wound, 
or  by  the  bursting  of  a  neighboring  abscess.  The  symp- 
toms are  obscure,  but  the  presence  of  rupture  of  the  duct 
might  be  diagnosed  by  the  flowing  ot  chyle  from  the  wound, 
or  by  the  accumulation  of  that  fluid  in  the  pleural  cavity. 

Chylous  urine,  probably  the  result  of  rupture  of  the  re- 
nal lymphatics,  will  be  considered  under  the  urinary  system. 

Neoplasms  of  the  h^mphatic  vessels  are  so  rare,  and  so  ob- 
scure, as  not  to  warrant  their  consideration  in  these  pages. 

2.  The  Lymphatic  Glands. — Enlargement  of  the  lymphatic 
glands  may  arise  from  various  causes. 

{a?)  Inflammatory. — This  may  be  the  direct  result  of  a 
blow,  but  more  commonly  arises  from  the  absorption  of 
irritating  material  from  an  abrasion.  Such  enlargement  is 
common  at  the  elbow,  axilla,  knee,  and  groin.  The  chain 
of  femoral  glands  may  enlarge  as  the  result  of  a  wound  on 
the  leg  or  foot,  while  irritation  on  the  penis  affects  the  in- 
guinal chain  (bubo).  The  glands  at  the  back  of  the  neck 
frequently  swell  where  there  exists  any  irritation  of  the 
scalp,  and  the  cervical  glands  become  enlarged  in  diphthe- 
ria and  scarlatina. 

(<^.)  Scrofula. — In  strumous  persons,  particularly  in  child- 
hood and  early  life,  the  glands  of  the  neck  enlarge,  slowly 
suppurate,  and  caseate.  In  cases  of  tabes  mesenterica  scro- 
fulous glands  may  be  felt  through  the  abdominal  wall. 

{c.)  Syphilis. — The  adenitis  (almost  invariably  inguinal) 
which  follows  a  soft  chancre  is  called  the  ''virulent  bubo." 
It  comes  on,  generally,  about  a  week  after  infection,  is  ac- 
companied with  acute  pain,  and  ends  in  suppuration.  The 
"multiple  bubo,"  which  follows  the  hard  chancre  after  au 


HEMOPOIETIC  SYSTEM.  63 

interval  of  about  three  or  four  weeks,  is,  as  a  rule,  painless; 
there  is  no  suppuration,  and  the  induration  proceeds  slowly 
from  gland  to  gland  in  the  inguinal  chain  until  all  are  af- 
fected. They  seldom  exceed  a  walnut  in  size,  are  hard,  and 
roll  about  freely  under  the  linger.  In  the  secondary  stage 
of  syphilis  many  of  the  lymph  glands  throughout  the  body 
are  enlarged  (particularly  at  the  back  of  the  neck  and  the 
inside  of  the  elbow). 

(d.)  Cancer. — In  the  neighborhood  of  cancerous  tumors 
the  lymphatic  glands  become  enlarged  and  hard,  and  con- 
stitute an  important  element  in  diagnosis  and  prognosis. 
The  most  common  example  of  this  is  the  enlargement  of 
the  glands  in  the  axilla  and  above  the  clavicle,  which  fol- 
lows carcinoma  of  the  breast. 

(^.)  Adenia^  or  Hodgkiiis  Disease. — This  affection  is  charac- 
terized by  an  enlargement  of  the  lymphatic  glands  through- 
out the  body.  They  may  attain  to  great  size,  but  do  not 
suppurate.  There  is  marked  anaemia,  a  diminished  number 
of  red  blood  corpuscles,  but  no  increase  of  the  white,  and 
the  spleen  is  generally  enlarged.  The  cervical  glands  are 
usually  the  first  to  be  affected. 

(/. )  Leucocyth(E7nia. — In  some  cases  of  this  disease  there 
is  a  general  enlargement  of  the  lymphatic  glands  through- 
out the  body,  along  with  that  of  the  spleen.  It  is  readily 
distinguished  from  adenia  by  the  increase  in  the  white 
blood  corpuscles  which  is  present. 

(^.)  In  the  Plague,  and  also  in  Anthrax^  Glanders,  and 
Farcy\  acute  glandular  swellings  form  in  the  axilla,  groin, 
and  neck. 

3.  The  Ductless  Glands. —  The  Spleen  has  been  already  con- 
sidered, under  the  abdominal  system,  and  need  not  be  again 
alluded  to. 

The  Thyroid. — The  very  rare  inflammation  and  simple  en- 
largement of  this  gland,  as  well  as  the  malignant  and  cystic 
growths  which  form  in  it,  belong  to  the  domain  of  surgery. 
There  remain  for  consideration  only  two  diseases : 

(^.)  Bronchocele,  or  Goitre,  is  an  endemic  disease,  prevail- 
ing chiefly  at  the  base  of  high  mountains.  The  thyroid  is 
enlarged,  the  whole  or  part  of  the  gland  being  affected,  and 
presses  upon  neighboring  parts,  leading  to  difficulty  of 
breathing  and  swallowing.  Goitre  is  often  associated  with 
mental  deficiency  (cretinism). 

(b.)  Exophthalmic  Goitre — Graves's  Disease. — In  this  affec- 


64  MEDICAL  DIAGNOSIS. 

tion  the  swelling  of  the  thyroid  (usually  the  right  lobe)  is 
of  a  vascular  character — soft,  elastic,  and  pulsating.  It  is 
accompanied  with  marked  pulsation  in  the  vessels  of  the 
head  and  neck,  palpitation  of  the  heart,  prominence  of  the 
eyeballs,  and  other  nervous  symptoms,  and  is  most  common 
in  females  below  middle  age. 

Thymus. — Diseases  of  the  thymus  hardly  come  within  the 
limits  of  possible  diagnosis,  except  those  lymphatic  and 
malignant  tumors  of  the  anterior  mediastium,  which  have 
their  starting-point  in  that  gland. 

BLOOD. 

The  examination  of  the  blood  has  of  late  years  attained 
to  such  importance  as  an  aid  to  diagnosis,  and  as  a  guide 
in  the  subsequent  treatment  of  many  diseases,  that  the 
various  processes  employed  demand  a  somewhat  minute 
description.  Limiting  ourselves  to  those  methods  which 
may  be  truly  called  clinical — /.<?.,  which  can  be  carried  out 
at  the  bedside  of  the  patient — and  therefore  excluding  the 
minute  chemical  analysis  which  can  only  be  performed  in 
the  laboratory,  and  for  which  the  comparative  infrequency 
of  blood-letting  gives  but  few  opportunities  during  the  life- 
time of  the  patient,  we  shall  find  the  lines  of  investigation 
to  be  mainly  three — 

1.  Microscopic  examination  of  the  blood. 

2.  Enumeration  of  corpuscles  it  contains. 

3.  Estimation  of  the  haemoglobin. 

I.  Microscopic  Examination  of  Blood. — To  obtain  a  drop 
of  blood  for  examination,  the  end  of  the  patient's  finger 
must  be  carefully  cleansed,  and  a  prick  made  with  a  needle. 
The  finger  must  not  be  squeezed  or  compressed  in  any 
way,  as  this  tends  to  alter  the  proportion  of  serum  and 
corpuscles  which  the  blood  contains.  The  drop  of  blood 
so  obtained  should  be'  received  on  a  clean  microscope  slide, 
the  cover-glass  applied,  and  the  microscopic  examination 
made  as  speedily  as  possible.  The  pathological  changes 
usually  met  with  may  be  divided  ijito  three  classes. 

(«.)  Alterations  in  the  form  of  the  normal  constituents 
of  the  blood. 

{b?)  Variations  in  their  number. 

(c!)  The  presence  of  foreign  substances. 

(a.)  Alterations  in  the  forfn  of  the  Normal  Constituents  of 


HiEMOPOIETIC   SYSTEM.  6$ 

the  Blood. — In  anaemia,  particularly  in  the  pernicious  variety 
of  that  disease,  the  red  blood  corpuscles  are  frequently 
found  to  be  much  diminished  in  size,  and  in  many  cases 
to  have  a  pale  appearance  due  to  loss  of  haemoglobin.  In 
other  instances  they  tend  to  assume  curious  and  irregular 
shapes  of  various  kinds.  The  changes  in  the  colorless  cor- 
puscles are  not  so  distinctive,  but  not  unfrequently  they 
may  be  found,  in  case  of  anaemia  and  leucocythaemia,  to 
be  abnormally  refractive,  and  to  contain  granules  resem- 
bling oil-globules.  In  various  cachectic  conditions  the  pro- 
toplasmic granules  which  are  to  be  found  occasionally  in 
normal  blood  become  much  increased  in  number,  and  ad- 
here together  so  as  to  form  larger  or  smaller  masses. 

(^.)  Variations  in  the  number  of  the  Blood  Corpuscles. — 
Whilst  in  many  cachectic  conditions,  as,  for  example,  in 
phthisis,  the  number  of  leucocytes  in  the  blood  may  be 
above  the  normal  (leucocytosis),  it  is  in  leucocythaemia 
that  this  increase  is  by  far  most  observable,  and  by  means 
of  the  microscopic  examination  of  the  blood  alone,  a  diag- 
nosis may  be  arrived  at.  The  number  of  leucocytes  pres- 
ent in  the  field  may  be  very  great,  even  in  pronounced 
cases  surpassing  that  of  the  red  corpuscles.  In  the  lym- 
phatic variety  of  the  disease  the  size  of  the  leucocytes  is 
very  much  that  of  ordinary  lymph  corpuscles,  and  they 
contain  as  a  rule  but  one  nucleus,  while  in  splenic  leuco- 
cythaemia they  are  larger  in  size,  and  usually  possess  more 
than  one  nucleus.  The  diminution  in  the  number  of  red 
corpuscles  in  anaemia,  though  not  so  striking  as  the  in- 
crease of  leucocytes  just  mentioned,  is  of  considerable  clini- 
cal interest.  • 

(<:.)  The  presence  of  Foreign  Substances. — Among  these 
may  be  mentioned,  in  the  first  place,  the  dark  brown  or 
black  pigment  granules,  which  are  som.etimes  found  in 
considerable  numbers  in  the  blood  after  malarious  fever. 
This  condition  is  spoken  of  as  melancemia. 

More  important  is  the  presence  of  the  various  micro- 
organisms which  appear  in  the  blood  in  certain  diseases. 
I  do  not  think  it  necessary  here  to  refer  to  more  than  one 
or  two  of  these  forms,  those  namely  in  which  the  diagnosis 
rests  much  or  mainly  upon  the  evidence  supplied  by  the 
microscopic  examination  of  the  blood. 

Bacillus  Anthracis. — This  form  of  organism,  which  is 
morphologically  identical  with  the  hay  bacillus  {B.  subtilis)^ 
is  found  in  the  blood  of  persons  suffering  from  the  disease 


66  MEDICAL  DIAGNOSIS. 

which  is  known  under  the  different  names  of  anthrax, 
woolsorter's  disease,  splenic  fever,  and  malignant  pustule. 
The  blood  is  found  to  be  filled  with  short  rods,  somewhat 
exceeding  in  length  the  diameter  of  a  red  blood  corpuscle, 
which,  as  the  disease  advances,  become  changed  into  long 
thread-like  filaments.  These  forms  are  usually  to  be  made 
out  with  very  considerable  ease,  but  they  will  be  rendered 
more  distinct  if  the  blood  be  allowed  to  dry  on  the  cover- 
glass,  and  be  then  stained  with  methyl  violet,  or  other  ap- 
propriate reagent,  in  the  manner  recommended  by  Koch. 

SpirochcEte  Obermeierii. — This  spirillum,  which  is  found  in 
the  blood  of  patients  suffering  from  recurrent  fever,  pos- 
sesses a  very  characteristic  appearance.  On  examining  a 
specimen  of  such  blood  with  the  microscope,  it  will  be  seen 
that,  moving  actively  among  the  blood  corpuscles,  are  a 
number  of  thread-like  organisms.  *  Their  length  is  usually 
three  or  four  times  greater  than  the  diameter  of  a  red  cor- 
puscle, and  in  shape  they  resemble  a  cork-screw.  Their 
movements  are  sometimes  so  powerful  as  to  move  the 
blood  corpuscles  with  which  they  may  come  in  contact  in 
their  course. 

Besides  these  there  are,  as  I  have  said,  a  considerable 
number  of  micro-organisms  met  with  in  the  blood  of  dif- 
ferent diseases,  but  although  their  form  is  usually  suffi- 
ciently distinctive,  yet  their  recognition  by  means  of  the 
microscope  cannot  be  held  to  have  as  yet  assumed  sufficient 
practical  diagnostic  importance  to  justify  any  detailed  de- 
scription in  these  pages. 

Mention  must,  however,  be  made  of  a  much  more  highly 
developed  parasite  which  is  occasionally  met  with. 

Filaria  sanguinis  ho7?iinis  is  the  name  which  Lewis  has 
given  to  a  nematode  worm  which  is  found  in  the  blood  of 
persons  suffering  from  chyluria,  certain  forms  of  endemic 
haematuria,  elephantiasis,  lymphoid  affections,  etc.  These 
filariae  are  exceedingly  minute,  and  are  the  sexually  imma- 
ture form  of  the  Filaria  Bancrofti,  a  long  thread-like  worm 
which  has  been  found  in  lymphatic  abscesses.  It  has  been 
shown  that  mosquitos  and  other  blood-sucking  insects  play 
an  important  part  in  the  dissemination  of  the  Filaria  san- 
guinis hoviinis, 

2.  Enumeration  of  the  Corpuscles  in  the  Blood. — This 
method  of  investigation,  which  was  first  attempted  by 
Vierordt,  has  been  followed  out  by  numerous  observers, 


HEMOPOIETIC   SYSTEM.  (y'J 

each  of  whom  has  described  a  special  form  of  apparatus  for 
the  purpose.  While  the  most  recent  modifications  of  Ma- 
lassez's  instrument,  or  the  apparatus  of  Abbe-Zeiss,  proba- 
bly give  the  most  rigidly  accurate  results,  I  will  here  des- 
cribe the  instrument  designed  by  Dr.  Gowers,*  which  is 
exceedingly  handy,  and  is  the  form  most  frequently  used 
in  this  country. 

Gowers's  Haeviacytoineter  consists  of  (i)  a  small  pipette, 
which  when  filled  to  the  mark  on  its  stem  contains  995 
cubic  millimetres;  (2)  a  capillary  tube  marked  to  contain 
five  cubic  millimetres.  Each  of  these  is  furnished  with  an 
india-rubber  tube  and  mouthpiece;  (3)  a  small  glass  jar  in 
which  the  blood  is  to  be  diluted;  (4)  a  glass  stirrer  for  mix- 
ing the  blood  and  the  solution  in  the  jar;  and  (5)  a  brass 
stage  plate  carrying  a  glass  slip,  on  which  is  a  cell  ^th  of  a 
millimetre  deep.  The  bottom  of  this  is  divided  by  inter- 
secting lines  into  yV^^  millimetre  squares.  Upon  the  top 
of  the  cell  rests  the  cover-glass,  kept  in  position  by  means 
of  two  springs. 

The  diluting  solution  may  vary.  One  which  answers 
well  consists  of  a  solution  of  sulphate  of  soda  in  distilled 
water,  having  a  specific  gravity  of  1025. 

When  an  observation  is  to  be  made,  995  cubic  millimetres 
of  the  solution  are  measured  by  means  of  the  pipette,  and 
placed  in  the  mixing  jar.  The  patient's  finger  is  now  to  be 
pierced  with  the  spear-pointed  needle  supplied  along  with 
the  instrument,  and  a  drop  of  blood  obtained  without  any 
squeezing  of  the  finger,  which,  as  I  have  already  said,  al- 
ters the  proportion  of  serum  and  corpuscles  in  the  blood. 
Five  cubic  millimetres  of  this  blood  are  drawn  into  the  cap- 
illary tube,  and  then  blown  into  the  diluting  solution  in  the 
jar,  any  superfluous  blood  being  previously  removed  from 
the  point  of  the  pipette  by  means  of  a  soft  cloth.  The  two 
fluids  are  well  mixed  by  rotating  the  stirrer  between  the 
finger  and  thumb,  after  which  a  small  drop  is  placed  in  the 
centre  of  the  cell,  and  the  cover-glass  applied.  The  drop 
must  lie  in  the  middle  of  the  cell,  and  must  not  not  touch 
its  sides.  The  slip  is  now  placed  upon  the  stage  of  a  mi- 
croscope, and  the  lens  focussed  for  the  squares,  which  are 
marked  out  by  lines  drawn  on  the  floor  of  the  cell.  In  a 
few  minutes  the    corpuscles   sink   through  the   drop   and 

*  Made  by  Hawksley,  300  Oxford  Street,  London.     A  full  description 
of  the  instrument  will  be  found  in  The  Practitioner  for  1878, 


68  MEDICAL  DIAGNOSIS. 

come  to  rest  on  these  squares.  The  number  in  ten  squares 
is  then  counted,  and  this  multiplied  by  10,000  gives  the  num- 
ber in  a  cubic  millimetre  of  blood.* 

The  most  recent  calculations  show  the  number  given  by 
Vierordt — 5,000,000  per  cubic  millimetre — is  approximately 
correct.  The  average  number  in  two  squares  is  100,  and 
Gowers  proposes  to  take  this  quantity  as  the  "  haemic  unit." 
This  is  a  very  convenient  way  of  calculating,  for  the  num- 
ber of  corpuscles  per  "  haemic  unit,"  />.,  in  two  squares 
(counting  ten  or  twenty  squares,  and  taking  the  mean),  ex- 
presses the  percentage  proportion  of  the  corpuscles  to  that 
of  health.  The  number  of  white  corpuscles  in  ten  or  twenty 
squares  is  easily  counted,  and  the  proportion  of  white  to 
red  ascertained.  The  normal  maximum  of  white  per  two 
squares  (haemic  unit)  is  .3. 

In  all  conditions  of  anaemia  and  cachexia  the  number  of 
red  corpuscles  undergoes  diminution,  and  by  examining 
their  number  from  time  to  time  we  can  obtain  most  valu- 
able and  trustworthy  indications  regarding  the  progress  of 
the  malady  and  the  effect  of  our  treatment. 

3.  Estimation  of  Haemoglobin. — Various  instruments  have 
been  devised  for  this  purpose  by  Malassez  and  others. 
That  of  Dr.  Gowers,f  which  I  prefer  both  on  account  of 
its  simplicity  and  the  accuracy  of  the  results  which  it  gives, 
consists  of  two  glass  tubes  of  the  same  diameter,  one  of 
which  contains  a  standard  color-solution  \  (glycerine  care- 
fully tinted  by  means  of  carmine  and  picrocarminate  of 
ammonia),  while  the  other,  in  which  the  blood  to  be  tested 
is  to  'be  diluted,  is  graduated  so  that  100  degrees  =  two 
cubic  centimetres.  There  is  also  a  capillary  pipette  gradu- 
ated to  hold  twenty  cubic  millimetres,  a  bottle  with  a  pipette- 
stopper  to  contain  distilled  water,  and  a  guarded  needle 
to  prick  the  finger. 

*  Probably  it  would  conduce  to  greater  accuracy  if  the  mixture  of 
blood  and  solution  were  accomplished  by  means  of  Potain's  "  Malan- 
geur,"  and  if  a  special  cover-glass  ground  absolutely  level  were  supplied 
along  with  this  apparatus;  and,  further,  if  this  cover-glass  were  fixed  in 
such  a  manner  to  the  slip  that  it  might  be  steadily  lowered  on  to  the 
drop  by  means  of  a  rack  movement.  All  of  these  arrangements  have 
been  adopted  by  Malassez  in  the  newest  model  of  his  instrument. 

f  Described  in  full  by  Dr.  Gowers  in  the  Transactions  of  the  Clinical 
Society  of  London\  vol.  xii.,  1879, 

X  The  tint  of  this  standard  solution  corresponds  exactly  to  that  of  a 
dilution  of  twenty  cubic  millimetres  of  blood  with  1980  cubic  millimetres 
of  distilled  water,  i.e.^  a  dilution  of  one  in  a  hundred. 


CIRCULATORY   SYSTEM.  69 

The  method  of  using  this  instrument  is  as  follows.  The 
two  tubes  having  been  placed  upright  in  the  small  wooden 
stand  supplied  for  the  purpose,  a.  few  drops  of  distilled 
water  are  placed  in  the  bottom  of  the  graduated  tube.  The 
blood  having  been  obtained  from  a  prick  in  the  manner 
already  described,  twenty  cubic  millimetres  of  the  blood 
are  measured  off  by  means  of  the  pipette,  and  injected  into 
the  distilled  water  in  the  graduated  tube,  which  must  then 
be  quickly  shaken  to  ensure  thorough  mixture.  More  dis- 
tilled water  must  now  be  added  drop  by  drop  until  the  tint 
of  the  diluted  blood  is  the  same  as  that  of  the  standard. 
The  degree  of  dilution  as  indicated  by  the  graduation  ex- 
presses the  amount  of  haemoglobin  as  compared  with  that 
of  the  standard,  and  as  this  is  a  dilution  of  one  hundred, 
the  degrees  of  dilution  required  to  obtain  the  same  tint 
represent  the  percentage  proportion  of  the  haemoglobin  to 
that  of  normal  blood.* 

If  the  corpuscular  richness  of  the  blood  is  ascertained  by 
means  of  the  hsemacytometer,  we  are  able  to  compare  this 
with  the  amount  of  haemoglobin  in  a  very  instructive  man- 
ner. Thus,  a  fraction,  of  which  the  numerator  is  the  per- 
centage of  haemoglobin,  and  the  denominator  the  percen- 
tage of  corpuscles,  will  express  the  average  value  of  each 
corpuscle. 


CHAPTER  VII. 

Circulatory  System, 
subjective   phenomena. 

Before  addressing  ourselves  to  the  physical  examination 
of  the  heart,  there  meet  us  for  consideration  certain  symp- 
toms of  a  more  or  less  subjective  kind. 

I.  Pain. — In  anaemic  persons,  and  particularly  in  women 
suffering  from  uterine  disease,  from  chlorosis,  or  from  ner- 
vous affections,  pain  over  the  region   of  the  heart  is  fre- 

*  Thus  if  the  tints  are  identical  when  the  dilution  has  reached  80  de- 
grees, the  blood  contains  only  80  per  cent  of  the  normal  quantity  of 
hsemoglobin. 


70  MEDICAL   DIAGNOSIS. 

quently  complained  of,  and  true  cardiac  pain  may  likewise 
be  simulated  by  neuralgia  in  the  chest  wall.  In  heart  dis- 
ease of  any  kind,  and  particularly  in  fatty  degeneration  as- 
sociated with  gout,  pain  may  be  a  more  or  less  prominent 
symptom.  In  its  most  pronounced  form — angina  pectoris 
— it  comes  on  in  recurring  attacks  of  short  duration,  but  of 
extreme  severity.  The  first  of  the  attacks  usually  occurs 
when  the  patient  is  making  some  exertion.  The  chest  feels 
as  if  held  in  a  vice,  the  pain,  which  is  always  severe,  and 
which  may  be  of  the  most  intense  character,  radiates  from 
the  heart  to  the  shoulders,  and  down  the  left  arm,  or  down 
both  arms  to  the  wrist,  breathing  almost  ceases,  the  coun- 
tenance sometimes  becomes  livid,  and  consciousness  may 
be  lost.  In  other  cases  the  attacks  may  be  very  frequent, 
several  in  a  day,  or  even  one  after  the  slightest  exertion  of 
body  or  of  mind.  The  attack  passes  off  as  rapidly  as  it 
came  on,  and  the  patient  may  be  free  from  its  repetition  for 
months  or  years.  The  pain  of  aortic  aneurism  is  more 
lancinating  and  more  continuous  than  angina  pectoris." 

2.  Palpitation. — The  abnormal  perception  of  excited  pul- 
sation in  the  heart  or  aorta  is  very  frequently  due  to  men- 
tal excitement,  to  dyspepsia,  flatulence,  anaemia,  or  nervous 
debility,  and  is  also  met  with  in  cases  of  exophthalmic 
goitre.  It  also  occurs  as  a  result  of  organic  disease  of  the 
heart,  and  in  such  cases  it  will  be  found  to  be  aggravated 
by  exertion.  Derangements  of  rhythm  will  be  noticed 
hereafter. 

3.  Fainting  {syncope)^  which  is  primarily  due  to  failure 
of  the  heart's  action,  is  usually  ushered  in  by  a  train  of 
symptoms  of  which  the  chief  are — pallor  of  the  face,  chilli- 
ness, cold  perspirations,  a  feeling  of  weakness,  of  sinking 
in  the  epigastrium,  and  of  sickness,  pulse  small  and  rapid, 
or  slow  and  irregular,  dimness  of  vision,  ringing  in  the 
ears,  and  gradually  increasing  unconsciousness.  Syncope 
may  be  due  to  organic  disease  of  the  heart,  to  nervous  dis- 
turbance of  the  cardiac  action  (central  or  reflex),  to  intense 
mental  emotion  (hysteria),  to  deficiency  of  the  blood  sup- 
ply to  the  heart  muscle,  or  to  want  of  blood  in  its  cavities. 


CIRCULATORY   SYSTEM.  7 1 

CHAPTER  VIII. 

Circulatory  System — (contmued). 

INSPECTION. 

The  cardiac  or  precordial  region  corresponds  to  the  lower 
part  of  the  anterior  mediastinum.  It  may  be  said  to  extend 
vertically  from  the  second  interspace  to  the  sixth  cartilage, 
and  transversely  from  the  apex-beat  to  a  point  about  three- 
quarters  of  an  inch  to  the  right  of  the  sternum. 

The  region  so  marked  out  overlies  the  heart,  and  the 
margins  of  both  lungs  which  overlap  it.  More  deeply  still 
lie  the  organs  contained  in  the  posterior  mediastinum. 

In  this  chapter  will  be  considered  (i)  the  form  and  ap- 
pearance of  the  praecordia;  and  (2)  the  various  pulsatory 
movements  which  show  themselves  on  the  walls  of  the 
thorax. 

Prcecordia. — A  slight  degree  of  bulging  of  the  thoracic 
wall  in  the  cardiac  region  is  more  readily  detected  by  sim- 
ple inspection  than  by  means  of  measurement.  It  may  be 
the  result  of  curvature  of  the  spinal  column  anteriorly  and 
to  the  left,  but  is  more  commonly  caused  by  cardiac  hyper- 
trophy, pericardial  effusion,  aneurismal  and  other  tumors 
adjacent  to  the  heart,  or  circumscribed  pleuritic  effusions. 
When  effusion  takes  place  into  the  pericardial  sac,  the  inter- 
costal spaces  widen,  they  become  raised  to  the  level  of  the 
ribs,  and  ultimately  may  even  protrude  beyond  them. 

Depression  of  the  praecordial  region,  on  the  other  hand, 
may  take  place  during  the  absorption  of  a  pericardial  ef- 
fusion, and  may  remain  permanently  if  adheston  has  taken 
place  between  the  visceral  and  parietal  layers  of  the  peri- 
cardial sac. 

Bulgings  caused  by  aneurisms  lie  almost  without  excep- 
tion above  the  fourth  rib. 

Pulsations. 

I.  The  Cardiac  Impulse. — In  health  the  apex-beat  is  found 
in  the  fifth  interspace,  about  two  inches  from  the  left  mar- 
gin of  the  sternum,  and  its  area  does  not  exceed  a  square 
inch  in  extent.  In  childhood,  however,  and  in  persons  who 
have  a  short  and  wide  thorax,  it  may  stand  as  high  as  the 
fourth  interspace,  and  may  be  thrown  somewhat  farther  to 


72  MEDICAL  DIAGNOSIS. 

the  left;  whilst  in  old  age,  and  in  persons  whose  thorax  is 
very  long  and  narrow,  the  cardiac  impulse  is  depressed  to 
the  sixth  interspace. 

While  natural  breathing  does  not  affect  its  position,  deep 
inspiration  and  expiration  cause  respectively  depression 
and  elevation  of  the  apex-beat. 

When  the  patient  lies  on  either  side,  the  apex-beat  is 
deflected  in  a  corresponding  direction.  This  alteration  is 
more  marked  towards  the  left. 

[Pathological  changes  in  the  position  of  the  apex-beat 
will  be  considered  under  the  head  of  Palpation.] 

Systolic  Indrawing  of  the  thoracic  wall  is  of  two  varieties. 
(i)  A  recession,  which  is  exactly  synchronous  with  each 
ventricular  systole;  and  (2)  an  indrawing,  which  immedi- 
ately succeeds  the  retirement  of  the  apex  of  the  heart  from 
the  chest  wall. 

The  former  variety  (which  is  of  little  practical  impor- 
tance) is  sometimes  met  with  in  healthy  persons  (particularly 
children),  in  whom  the  chest  walls  are  unusually  thin.  It 
occurs  in  the  third  and  fourth  interspaces,  and  is  simply  the 
result  of  that  recession  of  the  base  of  the  heart  which  is 
synchronous  with  the  forward  movement  of  the  ventricles. 
The  chest  walls  are  sucked  inwards  (or  rather  forced  in- 
wards by  atmospheric  pressure)  to  prevent  the  formation 
of  a  vacuum  behind  them  which  would  otherwise  take 
place. 

The  second  form  is  seen  at  the  apex,  aud  is,  according  to 
Skoda,  pathognomonic  of  adherent  pericardium.*  If  the 
adhesion  be  extensive,  not  merely  the  intercostal  space  but 
even  the  ribs  may  be  drawn  inwards,  following  the  apex  of 
the  heart, 

2.  Pulsation  at  the  Root  of  the  Neck  may  be  arterial  or 
venous. 

Pulsation  in  the  carotid  arteries  becomes  evident  when- 
ever the  heart's  action  is  increased  in  strength  (as  after 
great  bodily  exertion,  or  from  mental  excitement),  but  in 
its  most  pronounced  form  such  pulsation  is  seen  in  cases  of 
hypertrophy  of  the  left  ventricle,  along  with  aortic  incom- 
petence.    Pulsation  in  the  jugular  fossa  when  well  marked 

*  This  sign  is  not,  however,  invariably  present  in  such  cases,  and 
though  adherent  pericardium  is  by  far  its  most  common  cause,  yet  it 
may  occur  in  cases  in  which  the  normal  movements  of  the  heart  are 
otherwise  hindered  (Friedreich). 


CIRCULATORY   SYSTEM.  73 

usually  points  to  simple  or  aneurismal  dilatation  of  the 
aorta. 

Swelling  of  the  jugular  veins  is  found  in  cases  in  which 
there  is  some  obstruction  to  the  return  of  blood  to  the 
heart,  whether  that  obstacle  be  situated  in  the  systemic  or 
pulmonary  circulation.  If  from  any  cause  the  right  ven- 
tricle be  unable  to  empty  itself  completely  of  blood,  it  be- 
comes gorged,  and,  reacting  on  the  right  auricle,  causes  its 
dilatation;  while  the  auricle  so  dilated  in  its  turn  retards 
the  flow  of  blood  through  the  jugular  veins,  which  then 
exhibit  distension.  The  same  effect  will,  of  course,  be  pro- 
duced by  any  obstruction  to  the  return  of  blood  to  the 
heart,  whether  seated  in  the  lungs  themselves,  or  in  the 
mitral  orifice,  or  the  valves  which  close  it. 

This  distension  is  necessarily  accompanied  with  more  or 
less  of  a  pulsatory  movement  in  the  vein,  the  blood  being 
only  able  to  reach  the  heart  during  inspiration.  This,  how- 
ever, is  not  the  only  pulsatory  movement  which  the  veins 
in  this  region  exhibit  when  they  are  in  a  state  of  distension. 
The  systole  of  the  right  ventricle  causes  a  vibration  which 
passes  through  the  tightly-stretched  right  auriculo-ventricu- 
lar  valve,  and  the  thrill  thus  communicated  to  the  blood  in 
the  dilated  auricle  is  thence  transmitted  to  the  jugular 
veins.  In  this  case  the  tricuspid  valve  and  the  valves  at  the 
mouth  of  the  jugular  veins  are  competent,  and  there  is, 
therefore,  no  backward  flow  of  blood  into  auricle  or  vein; 
it  is  simply  the  impulse  which  is  transmitted.  This  we  can 
readily  satisfy  ourselves  of  by  compressing  the  right  jugu- 
lar vein  high  up  in  the  neck,  and  then  if  the  contents  of 
the  lower  part  of  the  vessel  be  pressed  out,  the  vein  will 
not  fill  again  from  below,  since  no  valvular  incompetency 
exists. 

When,  however,  the  tricuspid  valve  is  incompetent,  or 
when  the  valves  in  the  jugular  vein  cease  to  close  the  lumen 
of  that  vessel  (either  from  destruction  of  its  valves,  or  from 
extreme  dilatation  of  the  vein  preventing  the  valves  from 
doing  their  duty),  the  vein  when  so  emptied  will  be  seen  to 
fill  from  below  with  regular  pulsations  corresponding  to 
those  of  the  right  ventricle. 

Thus  is  formed  the  ''venous  pulse,"  one  of  the  most  im- 
portant signs  of  tricuspid  incompetence. 

Jugular  pulsation  may  occasionally  be  praesystolic  in 
rhythm,  the  movement  resulting  from  the  transmission  of 
the  impulse  of  the  auricular  systole  into  the  vein. 


74  MEDICAL  DIAGNOSIS. 

Sudden  collapse  of  the  jugular  veins  during  the  ventri- 
cular diastole  has  been  shown  by  Friedreich  to  be  a  sign  of 
pericardial  adhesions. 

3.  Epigastric  Pulsation  may  be  conveniently  divided  into 
two  groups  (i)  those  which  are  synchronous  with  the  ven- 
tricular systole;  (2)  those  which  follow  that  systole  after  a 
slight  but  appreciable  delay, 

{a?)  SyncJu^onous  tenth  the  Ventricular  Systole. — When  the 
right  ventricle  is  hypertrophied  and  dilated,  it  may  fre- 
quently be  felt  to  pulsate  in  the  epigastrium,  and  any  con- 
dition which  depresses  the  diaphragm  or  forces  the  heart 
towards  the  right  may  give  rise  to  this  pulsation.* 

The  liver  may  also  pulsate  in  the  epigastrium,  but  if  the 
impulse  is  exactly  systolic  in  rhythm,  it  can  only  be  occa- 
sioned by  direct  transmission  from  the  adjacent  right 
ventricle. 

{b?)  Delayed  Epigastric  Pulsation^  i.e.,  that  which  succeeds 
the  ventricular  systole  after  an  appreciable  interval,  may  be 
due  to  the  transmitted  impulse  of  the  abdominal  aorta. 
The  pulsation  is  then  somewhat  to  the  left  of  the  middle 
line;  it  extends  downwards  towards  the  umbilicus,  and  is 
not  diffused  laterally.  It  may  be  conducted  to  the  parieties 
by  means  of  tumors,  or  through  the  overlying  liver.  The 
pulsation  may  be  due  to  an  aneurism  on  the  abdominal 
aorta,  or  one  of  its  branches,  when  it  will  have  a  distensile 
character. 

The  venous  pulsation  which  has  been  already  noticed  as 
occurring  in  cases  of  incompetence  of  the  tricuspid  valve  is 
not  limited  to  the  jugular  veins,  it  also  takes  place  in  the 
inferior  vena  cava.  This  pulsation  may  be  communicated 
to  the  liver,  and  if  the  hepatic  veins  be  likewise  affected, 
pulsation  becomes  not  merely  heaving  but  distensile. f 

In  all  these  conditions  the  pulsation  follows  the  apex- 
beat  after  a  slight  interval  of  time.  The  delay  can  be  best 
appreciated  by  fixing  with  wax,  over  each  pulsating  point, 
a  bristle  carrying  a  small  flag. 

Systolic  indrawing  of  the  epigastrium  occurs  rarely,  and 
is  caused  by  extensive  pericardial  adhesions. 

*  Rosenstein  has  proposed  to  call  this  pulsation  "parepigastric,"  as  it 
lies  rather  at  the  border  of  the  left  ribs  than  in  the  centre  of  the  epigas- 
trium. 

f  To  discriminate  the  various  epigastric  pulsations  mentioned  requires 
the  use  of  palpation  as  well  as  inspection,  but  to  preserve  the  continuity 
of  the  subject,  they  are  all  grouped  together  in  this  chapter. 


CIRCULATORY   SYSTEM.  75 


TABULAR     STATEMENT    OF    VARIOUS    EPIGASTRIC    PULSATIONS. 

1,  Synchronous  with  the  ventricular  systole. 
(a.)  Pulsation  of  the  left  ventriclee. 

(d.)  Pulsation  of  the  liver  transmitted  from  the  left  ven- 
tricle. 

2.  Delayed. 

(a.)  Aortic  pulsation  (hysterical  or  other.) 

(d.)  Aortic  pulsation  transmitted  through  the  liver,  over- 
lying tumors,  etc. 

(c.)  Aortic  or  other  aneurisms  in  epigastrium  (distensile). 

(d.)  Pulsation  of  the  inferior  ve/ia  cava  in  cases  of  tricus- 
pid incompetence  transmitted  through  the  liver. 

(<f.)  Distensile  hepatic  pulsation  arising  from  a  venous 
pulse  in  the  hepatic  veins  in  cases  of  tricuspid 
incompetence. 

4.  Arterial  Pulsations  on  the  Thoracic  Wall. — Aortic  aneu- 
risms frequently  give  rise  to  visible  pulsation  in  the  upper 
part  of  the  thorax,  above  the  third  rib.  Such  pulsation  is 
systolic  in  rhythm,  being  as  nearly  as  possible  synchronous 
with  the  ventricular  systole.  If  the  ascending  portion  of 
the  arch  be  involved,  the  pulsation  usually  lies  to  the  right 
of  the  sternum;  if  the  transverse  portion  be  the  seat  of  the 
disease,  the  pulsation  is  more  in  the  middle  line;  and  if  the 
aneurism  affect  chiefly  the  descending  part  of  the  arch,  the 
pulsation  lies  to  the  right  side  of  the  sternum.  Aneurisms 
of  the  innominate  and  subclavian  arteries  also  give  rise  to 
visible  pulsation  in  the  walls  of  the  thorax.  Systolic  pul- 
sation at  the  second  left  interspace  is  sometimes  communi- 
cated to  the  surface  from  the  subjacent  pulmonary  artery 
in  cases  of  retraction  of  the  borders  of  the  lungs. 

A  diastolic  impulse  is  sometimes  to  be  seen  and  felt  over 
the  seat  of  the  aortic  and  pulmonary  valves  (second  right 
and  second  left  intercostal  spaces)  in  very  emaciated  per- 
sons, especially  where  the  borders  of  the  lungs  have  be- 
come retracted. 

5.  Capillary  Ptilsation  can  occasionally  be  observed  on  the 
cheeks,  beneath  the  nails,  or  in  the  line  of  congestion 
caused  by  drawing  a  sharp  point,  such  as  that  of  a  pencil, 
over  the  skin,  and  though  sometimes  occurring  indepen- 
dently of  that  cause,  is  usually  due  to  incompetence  of  the 
aortic  valves,  with  hypertrophy  of  the  left  ventricle. 


^^6  MEDICAL   DIAGNOSIS. 

CHAPTER   IX. 

Circulatory  System. 
palpation. 

Cardiac  Impulse.  —  Altered  in  position  —  Vertically  —  Horizontally — 
Altered  in  force — Altered  in  Extent — Thrills,  Endocardial  and  Exo- 
cardial. 

The  skilled  application  of  the  hand  to  the  cardiac  region 
gives  important  information  regarding  the  heart,  which  in- 
spection alone  is  not  fitted  to  communicate,  and  confirms 
much  that  inspection  has  already  indicated.  Palpation 
deals  chiefly  with  the  phenomena  of  the  cardiac  impulse, 
and  with  the  various  thrills  which  sometimes  occur  in  con- 
nection with  the  heart's  action. 

CARDIAC    IMPULSE. 

The  apex-beat  has  already  been  spoken  of  in  the  last 
chapter  in  its  normal  condition.  We  now  consider  the 
various  changes  which  it  may  undergo  in  disease — altera- 
tions in  position,  in  strength,  and  in  extent — remembering 
that  in  health  the  impulse  lies  between  the  fifth  and  sixth 
ribs,  about  two  inches  to  the  left  of  the  stel^num;  that  while 
ordinary  respiration  does  not  affect  its  position,  it  is  de- 
pressed and  elevated  to  a  very  slight  extent  by  deep  inspi- 
ration and  expiration;  and  that  when  the  patient  lies  on 
the  left  side  it  is  slightly  displaced  outwards. 

Alterations  in  the  position  of  the  Apex-beat. 

I.    Vertically. 

The  height  depends  simply  on  the  level  of  the  dia- 
phragm.* 

Pulmonary  emphysema  and  spasmodic  contraction  of  the 
diaphragm  cause  a  general  depression  of  the  diaphragm, 
while  collections  of  liquid  or  of  gas  in  one  pleural  cavity,  or 
in  the  pericardial  sac,  an  increase  of  the  weight  of  the  heart 
(particularly  from  hypertrophy  of  the  left  ventricle),  or  the 
presence  of  tumors  in  the  neighborhood  of  that  organ, 
produce  a  local  depression  in  the  diaphragm,  and  each  of 

*  With  the  exception  of  cases  of  pericardial  effusions,  when  the  dia- 
phragm may  be  depressed  and  the  apex-beat  simultaneously  raised. 


CIRCULATORY   SYSTEM.  77 

these  conditions  finds  expression  in  a  lowered  position  of 
the  apex-beat. 

On  the  other  hand,  if  the  diaphragm  be  raised  owing  to 
cirrhosis  of  one  lung,  or  contraction  following  the  absorp- 
tion of  a  pleural  effusion,  or  by  reason  of  increased  abdo- 
minal pressure,  the  result  of  tumors,  ascites,  meteorism, 
etc.,  the  apex-beat  will  be  correspondingly  elevated. 

2.  Laterally. 

(a.)  To  the  right. — Hypertrophy  and  dilatation  of  the  right 
ventricle  displace  the  apex-beat  from  its  normal  position 
toward  the  right.  In  slighter  cases  the  pulsation  is  greatest 
in  the  epigastrium,  but  in  those  which  are  more  marked, 
the  apex,  or  at  any  rate  that  portion  of  the  heart-wall  which 
represents  the  apex,  beats  under  the  right  edge  of  the  ster- 
num, or  even  farther  to  the  right.  Effusions  in  the  left 
pleural  cavity  also  push  the  heart  over  to  the  right  side; 
and  on  the  absorption  of  the  exudation  the  heart  returns 
again  to  its  normal  position,  provided  that  it  has  not 
become  bound  down  by  adhesions  in  its  abnormal  position. 
The  apex-beat  may  be  found  on  the  right  side  of  the  thorax 
in  cases  of  congenital  transposition  of  the  viscera. 

{p?)  To  the  left. — Hypertrophy  and  dilatation  of  the  left 
ventricle  not  only  depress  the  apex-beat,  but  also  move  it 
considerably  to  the  left.  In  cirrhosis  of  the  left  lung  the 
heart  follows  the  contracting  lung  towards  the  left,  and 
effusions  into  the  right  pleural  cavity  also  produce  a  move- 
ment of  the  apex-beat  in  this  direction,  when  they  are  of 
considerable  amount. 

Strength  of  the  Apex-beat  varies  much  even  in  healthy  in- 
dividuals, owing  to  varieties  in  the  thickness  of  the  chest- 
wall,  in  the  width  of  the  intercostal  spaces,  and  in  the 
extent  to  which  the  apex  is  overlapped  by  pulmonary  tissue. 
Pathologically,  the  differences  are  still  more  apparent. 

Diminished  force  of  the  cardiac  impulse,  even  to  the  ex- 
tent of  being  imperceptible  to  the    finger,  may  be  due  to — 

1.  Inti'insic  catises. — These  include  abnormal  innervation, 
fatty  degeneration  of  muscular  fibre  of  the  heart,  and  that 
inflammatory  change  which  follows  myocarditis  and  hyper- 
pyrexia of  long  duration,  and  lastly,  deficiency  of  proper 
blood  supply  and  interference  with  the  circulation. 

2.  Extrinsic  caiises. — When  the  visceral  and  parietal  layers 
of  the  pericardium  become  adherent,  the  movements  of  the 
apex   of  the  heart  are  so  interfered  with  that  all  cardiac 


78  MEDICAL  DIAGNOSIS. 

impulse  may  be  lost.  Effusions  of  fluid  or  gas  into  the 
pericardium  or  into  the  left  pleural  cavity,  as  well  as  inter- 
vention of  emphysematous  lung  tissue  between  the  heart 
and  the  thoracic  wall,  all  tend  to  weaken  the  apex-beat. 

Increase  in  force  of  the  cardiac  impulse  may  be  of  neuro- 
tic origin  ;  it  may  be  the  result  of  fever,  of  endocarditis,  of 
pericarditis,  or  of  any  condition  which  is  more  than  usually 
favorable  to  the  conduction  of  the  impulse,  but  by  far  its 
most  common  cause  is  hypertrophy  of  the  heart.  The 
heaving  impulse  which  results  from  hypertrophy  of  the 
left  ventricle  is  much  more  easily  detected  than  that  which 
hypertrophy  of  the  right  ventricle  occasions,  as  the  latter 
has  its  point  of  maximum  intensity  behind  the  sternum. 

The  rhythm  of  the  cardiac  pulsations  will  be  noticed  in 
the  remarks  made  on  the  arterial  pulse. 

The  Extent  of  the  Impulse. — Normally,  the  apex-beat  is 
not  perceptible  over  more  than  an  area  of  about  an  inch  in 
breadth,  and  is  limited  to  the  fifth  intercostal  space.  When 
the  pulsation  extends  much  beyond  such  limits,  it  is  abnor- 
mal. In  disease  the  apex-beat  not  unfrequently  becomes 
diffused  over  a  considerable  area,  and  this  may  result  from 
increased  action  of  a  normal  heart  (medication,  excitement, 
etc.);  from  cardiac  hypertrophy  ;  from  the  application  of 
an  unusually  extensive  area  of  the  heart  to  the  thoracic 
walls  (retraction  of  the  lungs);  or  merely  from  great  thin- 
ness of  the  chest-wall. 

Double  Apex-beat. — Independent,  non-synchronous  con- 
traction of  the  ventricles  has  been  met  with  in  a  few  rare 
cases  (Charcelay,  Le5^den,  Roy,  etc.),  where  the  systole  of 
the  right  ventricle  caused  a  pulsation  in  the  jugular  veins 
which  alternated  with  that  in  the  carotid  arteries. 

Thrills  may  be  felt  by  the  hand  applied  over  the  cardiac 
region,  and  these  are  of  two  kinds — 

I.  Endocardial  thrills^  caused  by  the  blood  current  being 
forced  through  a  small  opening.  The  pathological  condi- 
tion which  gives  rise  to  the  thrill  is  indicated  by  the  seat  of 
greatest  intensity  and  the  time  in  relation  to  the  various 
phenomena  of  cardiac  action. 

Thrills  in  the  mitral  area  (a  circle  with  a  radius  of  one 
inch  around  the  apex-beat)  are  systolic  or  praesystolic  ac- 
cording as  they  are  produced  by  incompetence  of  the  mitral 


CIRCULATORY   SYSTEM.  79 

valve  or  stenosis  of  the  orifice  which  that  valve  covers. 
Thrills  over  the  second  right  costal  cartilage  arise  from 
aortic  stenosis  or  incompetence  ;  in  the  former  case  being 
systolic,  and  in  the  latter  diastolic  in  rhythm.  Praesystolic 
and  systolic  thrills  in  the  tricuspid  area  indicate  respectively 
stenosis  of  the  orifice  and  incompetence  of  the  valve.  Very 
rarely  a  systolic  thrill  is  felt  over  the  pulmonary  artery, 
denoting  stenosis  of  the  pulmonary  orifice,  or  a  diastolic, 
indicative  of  regurgitation. 

2.  Pericardial  frictio?i-frcmtfus,  caused  by  the  rubbing  dur- 
ing the  heart's  action  of  the  two  pleural  surfaces  which 
have  been  rendered  rough  and  uneven  by  the  effusion  of 
lymph  ;  more  readily  detected  by  auscultation  than  by 
palpation. 


CHAPTER  X. 

Circulatory  System — (continued). 

PERCUSSION. 

The  heart,  lying  in  the  thoracic  cavity,  has,  in  its  normal 
condition,  the  following  relations  to  the  anterior  wall  of 
the  chest  : 

The  right  border^  formed  almost  entirely  by  the  right  auri- 
cle, stretches  in  a  slightly  curved  manner  from  the  second 
right  intercostal  space  downward  and  outward  to  the 
cartilage  of  the  fifth  rib  on  the  same  side,  just  at  its  junc- 
tion with  the  sternum.  The  left  border,  formed  by  the  left 
ventricle,  reaches  from  the  second  intercostal  space  on  the 
left  side  downward  and  outward  to  a  point  about  half  an 
inch  outside  of  the  apex-beat.  The  loiver  border  corre- 
sponds pretty  exactly  to  a  line  joining  the  sternal  end  of 
the  fifth  right  costal  cartilage  with  the  apex-beat.  The 
highest  portion  of  the  heart,  formed  by  the  appendix  of 
the  left  auricle,  reaches  a  level  which  may  be  indicated  by 
a  line  joining  the  lower  border  of  the  sternal  ends  of  the 
second  pair  of  costal  cartilages. 

To  percuss  the  heart  it  is  best  to  have  the  patient  recum- 
bent. No  strong  percussion  is,  as  a  rule,  required,  and  this 
is  specially  the  case  with  regard   to  the  absolute  dulness 


80  MEDICAL  DIAGNOSIS. 

where  the  tap  should  be  light.  In  addition  to  the  note 
elicited,  the  sense  of  resistance  perceived  during  percussion 
is  of  great  value. 

The  greater  portion  of  the  heart  is  separated  from  the 
chest-wall  by  the  overlapping  lung,  and  therefore  it  is  only 
the  small  uncovered  part,  consisting  of  the  right  ventricle, 
which  yields  on  percussion  a  dull  note.  This  area  of  abso- 
lute cardiac  dulness  is  readily  mapped  out.  Its  right  border 
extends  along  the  right  margin  of  the  sternum  (or  along  the 
mid-sternal  line  in  some  cases)  from  the  level  of  the  fourth 
to  that  of  the  sixth  costal  cartilage.  The  left  border  is  an 
irregular  line  stretching  from  the  upper  end  of  the  right 
border  to  the  apex-beat.  The  lower  edge  cannot  be  de- 
fined by  percussion,  because  at  this  point  the  cardiac 
merges  into  the  hepatic  dulness.  Its  position  can,  however, 
be  obtained  with  approximate  accuracy  by  drawing  a  line 
from  the  upper  limit  of  absolute  hepatic  dulness  on  the 
right  side  to  the  apex-beat.  The  area  thus  formed  is 
roughly  quadrilateral  in  shape  ;  and  not  only  do  its  extent 
and  position  vary  with  each  respiration,  but  they  are  also 
affected  by  the  position  of  the  person,  and  also  by  the  con- 
stant changes  of  the  diaphragm  in  respiration,  necessarily 
producing  corresponding  changes  in  the  lie  of  the  heart. 
The  condition  of  the  margins  of  the  lungs  (as  in  emphy- 
sema) have  also  an  important  influence  on  the  size  and 
position  of  the  area  of  absolute  cardiac  dulness.  The  vari- 
ations to  which  this  area  is  thus  liable  greatly  diminish  the 
value  of  its  condition  as  indicative  of  disease. 

The  region  of  absolute  dulness  is  increased  in — 

(i.)  Hypertrophy  a7id  Dilatation  of  the  Left  Ventricle,  when 
the  increase  takes  place  chiefly  downward  and  to  the  left. 

(2.)  Hypertrophy  and  Dilatation  of  the  Right  Ventj'icle. — In 
this  case  the  left  margin  is  little  interfered  with,  while  the 
fight  is  thrown  outward  toward  the  right. 

(3.)  Serotis  Effusion  into  the  Pericardium. — The  dulness 
here  takes  a  pyramidal  form,  being  limited  by  the  pericar- 
dial sac,  with  the  base  downwards,  resting  on  the  dia- 
phragm. 

(4.)  Increase  of  absolute  cardiac  dulness  may  be  simu- 
lated by  various  pathological  conditions  of  the  neighboring 
organs,  such  as  infiltration  of  the  margins  of  the  lungs, 
pleuritic  effusions,  etc. 

It  must  be  borne  in  mind,  however,  that  these  various 
diseased  conditions  of  the  heart  and  its  investing  sac  may 


CIRCULATORY   SYSTEM.  81 

be  present  without  giving  rise  to  any  appreciable  changes 
in  the  absolute  cardiac  dulness.  The  area  of  absolute  dul- 
ness  is  diminished,  or  entirely  lost   in — 

(i.)  Left pneumo-thorax^  where  the  collection  of  gas  in  the 
left  pleural  cavity  is  so  great  as  to  force  the  heart  to  the 
right.  The  area  of  dulness  is  usually,  in  such  cases,  still 
to  be  detected  to  the  right  of  the  sternum;  but  it  is  much 
diminished  in  size. 

(2.)  Emphysema^  when  well  pronounced,  entirely  does 
away  with  absolute  cardiac  dulness,  the  margins  of  the 
lungs  approaching  so  near  to  one  another  as  to  overlap  the 
heart  completely.  In  slighter  cases  the  area  is  only 
diminished  in  size. 

(3.)  In  the  rare  cases  in  which  free  gas  is  found  in  peri- 
cardium (pneumo-pericardium)  percussion  elicits  a  clear 
note  over  the  whole  cardiac  area. 

If,  then,  as  has  been  said,  the  indications  regarding  the 
heart  itself  obtained  by  examination  of  the  area  of  absolute 
cardiac  dulness  are  vitiated  by  various  pulmonary  condi- 
tions, we  must  seek  to  obtain  information  from  the  percus- 
sion of  that  portion  of  the  heart  which  is  covered  by  a 
more  or  less  thick  layer  of  lung. 

In  percussing  the  thorax,  as  we  pass  toward  the  cardiac 
area,  the  note,  which  is  at  first  purely  pulmonary  in  charac- 
ter, grows  more  and  more  dull,  until  the  limit  of  absolute 
cardiac  dulness  is  reached.  The  reason  of  this  change  in 
the  note  will  be  fully  discussed  when  the  subject  of  percussion 
comes  to  be  treated  of  as  a  whole  in  a  subsequent  chapter. 

It  is  by  noting  the  point  at  which  this  change  in  the  note 
occurs  that  the  position  of  the  outer  margin  of  the  heart 
can  be  determined  by  percussion.  This  is  called  the  area 
of  relative  cai'diac  dulness.  Now,  although  it  is  in  most  cases 
not  difficult  to  sketch  out  the  entire  area  of  relative  dul- 
ness, yet  for  ordinary  clinical  purposes  it  is  only  necessary 
to  percuss  in  two  directions — vertically,  parallel  to  the  left 
margin  of  the  sternum,  and  transversely,  at  the  level  of  the 
fourth  rib. 

I.  The  ve7'tical  line  is  thrown  about  one  inch  to  the  left  of 
the  sternum  in  order  to  avoid  the  aorta.  In  this  direction 
the  full  note  of  the  lung  becomes  impaired  at  about  the 
lower  edge  of  the  third  rib.  This  is,  then,  the  limit  of  rel- 
ative cardiac  dulness  in  this  situation.  Prolongation  of 
dulness  upwards  above  the  third  rib  (if  it  be  not  caused  by 
dislocation  of  the  heart  upward,  by  pulmonary  consolida- 


82  MEDICAL  DIAGNOSIS. 

tion,  or  by  the  bulging  of  an  aortic  aneurism)  arises  from 
pericardial  effusion.  On  the  other  hand,  increase  of  dul- 
ness  at  the  loiver  end  of  this  parasternal  line  (if  the  heart 
be  not  dislocated  downward)  indicates  enlargement  of  the 
left  lobe  of  the  liver. 

(2.)  The  h'ansverse  line  at  the  level  of  the  fourth  rib.  The 
left  border  of  the  heart  is  usually  marked  with  sufficient 
accuracy  by  the  position  of  the  apex-beat,  but  in  cases  of 
uncertainty  it  may  be  determined  by  percussing  from  with- 
out inward  in  the  direction  indicated,  when  it  will  be 
found  that  the  margin  of  relative  dulness  lies  a  short  dis- 
tance (J  to  I  inch)  to  the  left  of  the  absolute  cardiac  dul- 
ness. Increase  of  the  dulness  to  the  left  usually  indicates 
hypertrophy  and  dilatation  of  the  left  ventricle.  The  right 
margin  of  relative  dulness  at  the  level  of  the  fourth  rib 
indicates  the  amount  of  dilatation  of  the  right  auricle.  It 
is  usually  found  about  one  inch  to  the  right  of  the  margin 
of  the  sternum.  Increase  of  dulness  in  this  direction  there- 
fore takes  place  when  the  right  auricle  is  distended,  and 
indicates  obstruction  to  the  circulation.  This  obstruction 
is  probably  aortic  if  the  apex-beat  is  displaced  downward 
and  outward.  If  this  be  not  the  case,  it  is  either  mitral  or 
pulmonary. 

The  aortic  dulness  exists  in  the  normal  condition  simply 
as  a  slight  rounded  projection  from  the  upper  part  of  the 
relative  cardiac  dulness.  It  rises  as  high  as  the  upper 
margins  of  the  second  costal  cartilages. 

When  dilatation  of  the  aortic  arch  takes  place,  the  rela- 
tive dulness  becomes  better  marked,  and  passes  upwards 
and  towards  the  right,  impairing  the  note  over  the  nia?iu- 
brimn  sierni.  In  aneurism  of  the  aortic  arch,  the  area  of 
dulness  increases  correspondingly,  and  if  the  tumor  ap- 
proach near  to  the  sternum  there  is  produced  an  area  of 
absolute  dulness. 

When  the  aneurism  comes  to  press  firmly  on  the  breast- 
bone, the  dulness  which  this  gives  rise  to  is  not  absolutely 
limited  to  the  site  of  the  tumor,  but  extends  up  and  down 
the  sternum  to  a  variable  distance.  This  dulness  is  proba- 
bly in  some  measure  caused  by  the  obstruction  to  the  vibra- 
tion of  the  sternum  which  the  firm  pressure  of  the  tumor 
presents.  A  similar  alteration  in  the  percussion  note  may 
be  artificially  produced  by  pressing  heavily  on  the  sternum 
with  the  hand  while  percussion  is  being  made  at  a  neigh- 
boring point. 


CIRCULATORY   SYSTEM.  83 

CHAPTER   XI. 

Circulatory  System — (continued), 

AUSCULTATION    OF    THE    HEART.   • 

Cardiac  auscultation  is  almost  invariably  practised 
with  the  aid  of  a  stethoscope.  For  ordinary  purposes  a 
simple  wooden  instrument  suffices,  the  cup  of  which  accu- 
rately suits  the  ear  of  the  auscultator;  but  in  exceptional 
cases  a  double  stethoscope,  such  as  that  of  Alison,  may  be 
used,  which  fits  into  both  ears. 

On  listening  over  the  heart  two  sounds  are  to  be  heard, 
separated  by  two  pauses  of  unequal  length.  The  first 
sound,  which  is  considerably  the  more  prolonged  of  the 
two,  is  followed  by  a  short  pause:  to  it  succeeds  the  short 
second  sound,  and  finally  a  long  pause.  At  the  apex  of  the 
heart  the  first  sound  is  the  louder  of  the  two,  the  rhythm 
being  there  trochaic  (~""),  while  at  the  base  the  accent  is 
thrown  upon  the  second  sound,  as  in  the  iambus  ("""). 

Associated  more  or  less  intimately  as  these  sounds  are 
with  the  valves  of  the  heart,  it  is  necessary  for  the  student 
to  have  a  clear  conception  of  the  position  which  these 
structures  occupy  in  relation  to  the  anterior  thoracic  wall. 

The  Mitral  Valve,  which  is  situated  on  a  plane  considera- 
bl}''  posterior  to  those  in  which  the  other  valves  lie,  may  be 
said  to  correspond  to  the  sternal  end  of  the  third  left  costal 
cartilage,  projecting  more  or  less  upward  and  downward 
into  the  adjacent  intercostal  spaces. 

The  Tricuspid  Valve. — The  attached  edge  of  this  valve 
corresponds  to  a  line  drawn  slantingly  across  the  sternum 
from  the  third  left  intercostal  space  to  the  fifth  right  costal 
cartilage. 

The  Aortic  Valves  lie  horizontally,  opposite  a  line  joining 
the  middle  of  the  sternum  and  the  inner  end  of  the  third 
left  costal  cartilage. 

The  Pubnona7'y  Valves  are  also  placed  horizontally,  slightly 
higher  and  more  to  the  left  than  the  aortic,  corresponding 
to  the  upper  border  of  the  third  left  costal  cartilage,  or  to 
the  second  left  interspace. 

It  will  thus  be  seen  that,  in  relation  to  the  chest-wall, 
these  valves  lie  very  close  to  one  another,  a  superficial  area 


84  MEDICAL  DIAGNOSIS. 

of  half  an  inch  square  including  a  portion  of  all  four 
(Walshe).  The  sounds  produced  in  connection  with  these 
valves  are,  however,  best  heard,  not  immediately  over  them, 
but  at  that  point  on  the  chest- wall  at  which  the  cavity  into 
which  the  vibrating  blood  is  flowing  approaches  nearest  to 
the  surface.  Naturally,  this  point  where  the  sound  is  most 
intense  varies  in  each  case,  and  hence  we  have  four  areas 
for  auscultation. 

The  Mitral  Area  is  a  circle  about  an  inch  in  diameter, 
surrounding  the  apex-beat.  This  is  the  only  point  at  which 
the  left  ventricle  comes  in  contact  with  the  chest-wall. 

The  Tricuspid  Area  embraces  the  lower  part  of  the 
sternum,  particularly  the  left  border  at  the  level  of  the 
fourth,  fifth,  and  sixth  cartilages. 

The  Aortic  Area. — The  aorta  approaches  nearest  to  the 
chest-wall  at  the  second  right  costal  cartilage,  and  conse- 
quently the  aortic  area  is  situated  at  this  point. 

The  Pulmonary  Area  corresponds  to  the  second  left  inter- 
costal space  (Von  Dusch),  or  to  the  third  left  costal  cartilage. 

The  cause  of  the  heart-sounds  heard  in  these  various 
areas  may  be  briefly  indicated  as  follows: 

The  first  sound  (systolic),  heard  in  the  mitral  and  tricuspid 
areas  and  synchronous  with  the  ventricular  systole,  is 
formed  partly  in  connection  with  the  left  ventricle,  and 
partly  in  connection  with  the  right.  In  each  case  its  mode 
of  production  is  similar,  and  depends  (in  all  probability) 
upon  two  factors.  The  first  of  these,  as  was  shown  by 
Rouanet  as  early  as  1832,  is  the  vibration  of  the  auriculo- 
ventricular  valves,  arising  from  the  sudden  tension  caused 
by  the  ventricular  contraction;  and  the  second  is  the  mus- 
cular vibration  in  the  muscular  fibre  of  the  ventricle,  which 
takes  place  during  its  contraction  (muscle  sound). 

The  first  sound,  as  heard  in  the  aortic  and  pulmonary 
areas,  is  probably  to  be  considered  as  due  to  the  conduction 
of  the  mitral  and  tricuspid  sounds  to  the  base  of  the 
heart.* 

The  second  sound  (diastolic)  heard  in  the  aortic  and  pul- 
monary areas  has  its  origin  in  the  vibrations  produced  in 
the  semilunar  valves  at  the  orifices  of  each  of  these  vessels 


*  According  to  Heynsius,  however,  the  first  sound,  at  the  base  of  the 
heart,  arises  independently  at  the  orifices  of  the  aorta  and  pulmonary 
artery,  and  is  the  result  of  vibrations  arising  in  the  blood  currents  which 
are  propelled  into  these  two  vessels  during  the  ventricular  systole. 


CIRCULATORY   SYSTEM.  85 

during  the  diastole  of  the  heart,  by  the  blood  being  forced 
back  upon  these  valves. 

The  second  sound,  as  heard  in  the  mitral  and  tricuspid 
areas,  is  merely  the  aortic  and  pulmonary  sound  conducted 
to  the  apex. 

It  is  evident  that  we  have  thus  to  deal  with  four  sounds 
during  the  course  of  the  cardiac  revolution,  which  arise  en- 
tirely independently  of  one  another. 

Two  systolic  sounds  originate  at  the  mitral  and  tricuspid 
valves,  and  in  the  muscular  fibre  of  the  ventricles;  and  two 
diastolic  sounds  are  caused  by  vibration  of  the  semilunar 
valves  at  the  aortic  and  pulmonary  orifices. 

Of  these,  the  first  two  are  synchronous,  and  are  conse- 
quently heard  as  one  sound,  and,  as  the  last  two  also  take 
place  almost  simultaneously,  only  two  sounds,  a  systolic 
and  a  diastolic,  are  audible  over  the  cardiac  area.  The 
systolic  sound  marks  accurately  the  commencement  of  the 
ventricular  systole,  and  the  diastolic  expresses  with  equal 
precision  the  instant  at  which  the  diastole  of  the  heart 
begins. 

The  changes  in  the  cardiac  sounds  which  disease  pro- 
duces are  of  two  varieties — (i)  Alterations  in  the  normal 
heart  sounds;  and  (2)  murmurs,  or  adventitious  and  abnor- 
mal sounds. 

MODIFICATIONS    OF    THE    NORMAL    HEART    SOUNDS. 

The  normal  sounds  may  be  modified  in  disease  as  regards 
intensity,  purity,  quality,  etc.  It  will  suffice  to  consider 
such  changes  under  the  three  following  heads: 

■f- 

I.  Variations  in  Intensity  (intensified  or  enfeebled) — 
[a.)  Intensified. 

This  takes  place  with  regard  to  all  the  heart  sounds 
under  the  influence  of  mental  or  bodily  excitement,  pyrexia, 
etc.,  or  in  emaciated  persons,  simply  on  account  of  the  thin- 
ness of  the  chest- walls,  or  finally,  as  a  result  of  improved 
conduction  occasioned  by  condensation  of  the  pulmonary 
tissue,  or  by  the  bulging  of  an  aortic  aneurism. 

When  the  accentuation  is  limited  to  one  sound,  as  heard 
in  a  particular  area,  it  may  result  (i)  from  the  better  con- 
duction through  consolidated  lung-tiss.ue  (particularly  in 
the  case  of  the  second  sound  at  the  base  of  the  heart),  (2) 
from  hypertrophy  of  the  walls  of  a  particular  cavity  of  the 


86  MEDICAL  DIAGNOSIS. 

heart,  or  (3)  it  may  arise  from  increased  tension  in  the 
column  of  blood  which  presses  back  on  the  valves. 

Intensification  is  most  significant  when  found  in  connec- 
tion with  the  second  sound  in  the  aortic  or  pulmonary 
areas.  In  order  to  determine  that  either  of  these  sounds  is 
accentuated  it  is  only  necessary  to  compare  it  with  the 
other,  always  bearing  in  mind,  however,  that  in  the  normal 
condition  the  aortic  sound  is  louder  than  the  pulmonary. 

Accentuation  of  the  ao?'tic  second  sotcnd  3.Yise:S  from  increase 
of  the  arterial  tension.  It  is  also  met  with  in  dilatation  of 
the  aortic  arch,  and  is  most  marked  in  cases  of  aneurism  of 
the  arch,  where  there  is  hypertrophy  of  the  left  ventricle, 
but  in  which  the  sigmoid  valves  are  still  competent. 

Accentuation  of  the  pulmonary  second  sound  is  found  wher- 
ever there  is  increased  pressure  in  the  pulmonary  artery. 
It  is  a  sign  that  some  hindrance  exists  to  the  circulation  in 
the  lungs,  and  it  is  well  marked  in  cases  of  mitral  stenosis 
and  mitral  incompetence. 

(^.)  The  sounds  may  be  enfeebled  by  reason  of  bad  conduc- 
tion through  thick  chest-walls,  emphysematous  lungs, 
pleural  effusions,  etc.,  or  they  may  be  audible  with  diffi- 
culty on  account  of  loud  sounds  in  the  neighboring  lungs. 
Weakness  of  particular  sounds  is  chiefly  seen  in  connection 
with  affections  of  the  myocardium,  as  after  typhus,  in  fatty 
degeneration  of  the  cardiac  muscle,  etc. 

2.  Impurity  of  the  Sounds. — A  heart  sound  is  said  to  be 
impure  when  it  wants  the  clearness  and  definition  of  normal 
sounds,  or  when  it  consists  of  or  is  accompanied  by  irregu- 
lar vibrations.  Such  slight  changes  do  not  amount  to  a 
murmur,  but  in  practice  an  impure  sound  is  not  readily 
distinguished  from  one  accompanied  by  a  soft  murmur. 

Impurity  in  the  heart  sounds  may  be  caused  by  thicken- 
ing of  the  valves,  irregular  tension,  and  closure  of  the  dif- 
ferent cusps  of  the  valve. 

Impurity  is  of  little  diagnostic  importance. 

3.  Reduplication  of  the  Heart  Sounds. — Not  uncommonly 
the  heart  sounds  become  doubled,  each  cardiac  cycle  giving 
rise  to  three,  or  even  four,  separate  sounds.  On  careful  ex- 
amination, it  will  be  found  that  one  or  other  sound  has  be- 
come broken  up  into  two.  Reduplication  frequently  occurs 
in  health,  and  is  then  intimately  associated  with  respira- 
tion, and  the  changes  in  the  intrathoracic  pressure  thereby 


CIRCULATORY   SYSTEM.  Zy 

produced.  The  first  sound  is  reduplicated  at  the  end  of 
expiration  and  the  beginning  of  inspiration,  while  the 
second  sound  is  doubled  at  the  end  of  inspiration  and  the  be- 
ginning of  expiration.  Such  reduplication  has  no  peculiar 
significance,  and  only  indicates  that,  in  the  case  of  the  first 
sound,  the  auricular  pressure  on  the  right  side  of  the  heart  is 
increased,  and  retards  the  closure  of  the  tricuspid  valve;  and, 
in  the  case  of  the  second  sound,  that  the  pressure  in  the 
pulmonary  artery  is  increased,  and  so  the  closure  of  the 
pulmonary  valves  is  accelerated. 

In  disease,  reduplication  is  more  marked  and  constant. 
It  is  frequently  found  in  connection  with  the  second  sound 
in  cases  of  mitral  constriction  and  lung  disease,  from  the 
abnormally  high  tension  in  the  pulmonary  artery  thereby 
produced.  It  may  also  arise  in  cases  of  aortic  stenosis. 
Reduplication  of  the  first  sound  may  be  produced  by  irreg- 
ular contraction  of  capillary  muscles,  or,  in  very  rare  cases, 
by  a  synchronous  contraction  of  the  ventricles,  in  addition 
to  its  origination  from  differences  of  blood  tension  as  in 
health. 

MURMURS. 

The  murmurs  which  are  met  with  in  connection  with  the 
heart's  action  are  divided  into  two  groups:  (i)  Endocar- 
dial, or  those  which  arise  within  the  heart;  and  (2)  Exocar- 
dial,  or  those  originating  in  connection  with  the  outer  sur- 
face of  that  organ. 

1.  Endocardial  Murmurs. — Murmurs,  or  abnormal  sounds, 
differ  from  the  natural  heart  sounds  by  being  more  pro- 
longed, and  less  sharply  defined.  Those  which  are  of  en- 
docardial origin  all  arise  from  oscillations  or  vibrations  in 
the  blood  stream,  as  it  passes  through  a  narrow  opening 
into  a  wider  space  beyond. 

To  go  more  particularly  into  the  physical  question  of 
the  origin  of  murmurs,  we  must  put  away  from  our  minds 
the  idea  that  such  murmurs  are  ever  caused  by  rubbing  of 
the  blood  stream  upon  roughnesses  or  irregularities  on  the 
val-\fes  or  orifices  of  the  heart.  Such  a  state  of  matters  is 
physically  impossible;  for  when  a  fluid  streams  through  a 
tube,  the  walls  of  which  it  wets  (as  blood  does  the  endocar- 
dium), a  thin  layer  of  the  fluid  becomes  attached  to  the 
inner  wall  of  the  tube  by  the  force  of  cohesion,  and  conse- 
quently, seeing  that  the  current  itself  never  comes  in  con- 


88  MEDICAL  DIAGNOSIS. 

tact  with  the  tube- wall,  no  friction  between  the  two  is  pos- 
sible (Neumann,  Helmholz,  etc.) 

When  a  fluid  is  passing  along  a  tube  of  uniform  calibre 
no  murmur  arises,  unless  the  rapidity  of  flow  is  very  great. 
The  blood  current  is  never  rapid  enough  to  give  rise  to  a 
murmur  under  these  conditions.  But  when  a  constriction  . 
exists  in  the  tube,  and  the  fluid  is  thus  forced  to  pass  from 
a  narrow  into  a  wider  portion,  a  murmur  readily  arises; 
and  the  greater  the  difference  between  the  lumen  at  the  two 
points  the  more  easily  is  the  murmur  produced;  or,  in  other 
words,  the  less  rapidity  of  current  is  required  for  its  pro- 
duction.* It  is  in  this  way,  and  under  such  conditions,  that 
all  such  cardial  murmurs  arise.  Whenever  the  blood  stream 
passes  with  sufficient  velocity  through  a  narrow  orifice  into 
a  wider  space  beyond,  there  will  be  such  friction  between 
the  fluid  particles  as  to  give  rise  to  sonorous  vibrations  in 
the  fluid,  as  when,  for  example,  a  rent  occurs  in  the  aortic 
or  mitral  valves,  or  when  the  orifices  they  guard  become 
narrowed  by  disease. 

In  the  production  of  murmurs  there  enters,  however, 
another  factor  which  must  not  be  entirely  lost  sight  of,  viz. 
— the  condition  of  the  blood.  So  early  as  1837  it  was 
shown  f  that  the  ease  with  which  murmurs  could  be  pro- 
duced by  driving  fluids  of  different  density  through  veins 
stood  in  inverse  ratio  to  the  density  of  the  fluid,  and  this 
observation  has  been  confirmed  by  many  subsequent  ex- 
perimenters, among  whom  may  be  mentioned  Weber,  | 
Nolet,  §  and  Richardson.  ||  It  was  found,  in  particular, 
that  when  water  was  added  to  blood  a  murmur  was  more 
easily  produced  than  when  blood  alone  was  used,  and  this 
observation  has  a  very  important  bearing  upon  anaemic 
murmurs,  and  particularly  those  which  arise  in  veins,  as 
will  be  hereafter  shown. 

Endocardial  Murmurs  are  of  two  varieties — (i)  Those  of 
valvular  origin,  and  (2)  those  of  other  than  valvular  origin. 

Of  these,  the  latter  class  is  so  rare  that  it  is  well  invaria- 
bly to  endeavor  to  associate  a  murmur  with  a   particular 

*  That  such  murmurs  are  not  due  to  the  vibration  of  Savarts's  "  viine 
fluide"  is  shown  by  the  fact  that  the  murmur  may  arise  in  tubes  of  uni- 
form calibre  where  no  such  "  veins"  are  formed. 

I  J^/^^  Williams,  on  the  Pathology  of  Diseases  of  the  Chest.  London, 
1840. 

%  Arch,  f  physiol.   Heilkunde,  xiv. 

§  Arch,  der  Heilkunde,  xii.     1871.         1|  Med  Ti?nes  and  Gazette,  1868. 


CIRCULATORY   SYSTEM.  89 

valve  or  orifice,  and  only  in  the  event  of  failure  in  such  an 
attempt,  to  consider  the  possibility  of  a  non-valvular  cause. 

Having  ascertained  the  presence  of  a  murmur,  there  are 
three  points  which  should  be  carefully  noted — (i)  The 
rhythm  of  the  murmur,  /.<?.,  the  particular  period  in  the  car- 
diac contraction  with  which  it  corresponds  (auricular  or 
ventricular  systole  or  diastole,  etc.);  (2)  The  point  of  maxi- 
mum intensity  and  the  direction  of  propagation;  (3)  The 
condition  of  the  normal  heart  sound  at  the  valve  or  orifice 
at  which  the  murmur  is  supposed  to  originate. 

(i.)  Rhythm. — To  ascertain  the  rhythm  of  a  murmur  it  is 
necessary  to  lay  a  finger  upon  the  apex-beat  or  upon  the 
carotid  artery  while  we  auscultate.  This  gives  the  time  of 
the  ventricular  systole,  and  enables  us  to  say  which  is  the 
first  and  which  the  second  sound,  and  consequently  t^e 
rhythm  of  the  murmur  can  be  readily  ascertained.  If, 
however,  the  cardiac  pulsations  exceed  90  per  minute,  it 
may  be  impossible  thus  to  time  the  murmur,  and  in  such 
cases  we  must  wait  till  rest  and  appropriate  medication 
have  reduced  the  rapidity  of  the  heart's  action. 

(2.)  Point  of  Maximum  Intensity  and  Direction  of  Propaga- 
tion.— It  has  been  already  stated  that  the  normal  heart- 
sounds  are  heard  with  most  distinctness  in  various  areas 
according  to  the  valve  or  orifice  at  which  they  arise.  These 
sounds  are  conducted  in  the  direction  of  the  blood  current, 
and  are  best  heard  where  the  cavity  into  which  the  current 
flows  approaches  nearest  to  the  surface  of  the  body.  The 
same  holds  good  for  murmurs,  every  endocardial  murmur 
of  valvular  origin  having  its  point  of  maximum  distinct- 
ness in  one  of- these  four  areas,  and  being  of  mitral,  tricus- 
pid, aortic,-  or  pulmonary  origin,  according  as  it  is  best 
heard  in  the  mitral,  tricuspid,  aortic,  or  pulmonary  area. 
(Two  exceptions  to  this  rule  however  exist,  viz. — (i)  a  mi- 
tral systolic  murmur,  which  is  sometimes  best  heard  an 
inch  to  the  left  of  the  pulmonary  area,  and  (2)  an  aortic 
diastolic  murmur  which  is  occasionally  most  intense  at  the 
xiphoid  cartilage.) 

Having  satisfied  ourselves  as  to  the  rhythm,  and  the  point 
of  greatest  intensity  (and  consequently  the  seat  of  origin) 
of  the  murmur,  it  is  a  matter  of  simple  reasoning  to  dis- 
cover its  mode  of  production.  Thus,  for  example,  a  systolic 
mitral  murmur  can  only  be  one  of  regurgitation  through 
incompetence  of  the  valve.  A  praesystolic  mitral  murmur, 
on  the  other  hand,  must  result  from,  stenosis  of  the  mitral 


90  MEDICAL  DIAGNOSIS. 

orifice,  since  it  occurs  at  the  instant  when  the  blood  is  being 
propelled  by  the  auricular  systole  through  the  mitral  ori- 
fice into  the  ventricle.  We  shall  consider  the  causation  of 
each  particular  murmur  farther  on. 

The  direction  of  the  conduction  of  murmurs  may  be  of 
use  in  indicating  their  origin.  Stated  generally,  it  may  be 
said  that  systolic  mitral  murmurs  are  conducted  toward 
the  left  axilla,  and  to  the  angle  of  the  left  scapula;  tricus- 
pid murmurs  are  heard  over  an  area  corresponding  to  the 
right  ventricle;  aortic  murmurs  are  propagated  up  and 
down  the  sternum  and  into  the  arteries;  and  finally,  pul- 
monary murmurs  are  usually- not  audible  outside  of  that 
area. 

(3.)  The  Condition  of  the  Normal  Sound  at  the  Orifice  at 
which  the  Murmur  origi?iates. — The  presence  of  a  normal 
sound,  more  or  less  obscured  by  the  accompanying  mur- 
mur, indicates  that  the  valve  is  not  entirely  destroyed.  The 
method  of  auscultation  suggested  by  Gendrin  is  of  value  for 
the  purpose  of  ascertaining  this.  He  recommends  the  ear 
to  be  slightly  raised  from  the  stethoscope,  the  instrument 
remaining  unmoved,  when  the  sound  will  become  more  and 
the  murmur  less  audible.  The  real  value  of  the  presence 
of  a  cardiac  sound  as  an  indication  of  the  state  of  the  valve 
is  very  questionable.  In  the  case  of  aortic  disease,  the 
auscultation  of  the  arteries  gives  much  more  reliable  results. 

The  character  of  the  murmur  (soft,  blowing,  rasping, 
whistling,  etc.)  is  of  little  diagnostic  value.  As  a  general 
rule,  direct  murmurs  (those  which  arise  in  the  blood  current 
as  it  is  flowing  in  its  normal  direction)  are  rough;  whereas 
indirect  murmurs  (those  which  flow  in  a  direction  contrary 
to  that  of  the  normal  current)  are  soft. 

Having  determined  the  rhythm  and  seat  of  the  murmur, 
it  is,  as  I  have  already  said,  no  very  difficult  matter  to  infer 
the  manner  of  its  causation.  This  is  done  by  simply  bring- 
ing to  mind  what  is  happening  at  the  valve  in  question 
during  the  particular  period  at  which  the  murmur  is  heard. 
In  order  to  make  this  plain  we  will  now  consider  very 
briefly  the  various  murmurs  met  with  in  connection  with 
each  valve. 

Mitral  mzirmurs  are  systolic,  diastolic,  or  prsesystolic  in 
rhythm,  according  as  they  occur  during  the  ventricular 
systole,  the  diastole,  or  immediately  before  the  ventricular 
systole  {i.e.,  during  the  auricular  systole.) 

Mitral  systolic  7nurmurs, — These  murmurs,  originating  at 


CIRCULATORY    SYSTEM.  9I 

the  mitral  valve  during  the  ventricular  systole,  indicate  that 
from  some  cause  the  valve  does  not  completely  cover  the 
orifice,  but  allov^rs  a  part  of  the  blood  contained  in  the  ven- 
tricle to  be  forced  back  into  the  auricle.  This  incompe- 
tence of  the  mitral  valve  is  the  result  of  one  of  two  pro- 
cesses; either  the  valve  itself  has  become  altered  in  shape, 
or  the  orifice  has  increased  in  size,  so  that  the  valve  which 
formerly  sufficed  to  occlude  it  is  not  now  sufficiently  large. 

The  former  condition  arises  as  a  result  of  subacute  and 
chronic  endocarditis  (caused  in  connection  with  rheuma- 
tism, syphilis,  child-birth,  scarlatina,  etc.)  The  valves  be- 
come thickened  and  shrivelled  up,  and  so  the  incompetence 
originates. 

The  second  condition  (viz.,  increase  in  the  size  of  the 
mitral  orifice)  is  found  in  all  diseases  in  which  relaxation 
of  the  cardiac  muscle  takes  place  to  a  marked  extent,  as  in 
typhus,  typhoid,  relapsing,  and  rheumatic  fevers;  in  scarla- 
tina, measles,  erysipelas,  smallpox;  and  not  least  impor- 
tantly, in  chorea  and  in  various  forms  of  anaemia,  particu- 
larly in  chlorosis.  In  all  these  conditions,  the  myocardium 
is  so  softened  and  stretched  as  to  allow  the  mitral  orifice 
to  become  too  large  to  be  covered  by  the  valve.  Regurgita- 
tion of  blood  takes  place  into  the  auricle;  and  in  passing 
from  a  narrow  orifice  into  a  cavity  sonorous  vibrations 
arise  in  the  fluid,  in  the  manner  already  described.  In 
these  cases  the  formation  of  a  murmur  is  no  doubt  aided 
by  the  watery  condition  of  the  blood,  in  the  manner  already 
described. 

Mitral  systolic  murmurs  are  usually  heard  with  greatest 
distinctness  in  the  mitral  area,  and  are  propagated  toward 
the  left  axilla  and  the  angle  of  the  left  scapula.  Occasion- 
ally, however,  they  are  most  audible  a  little  to  the  outside 
of  the  pulmonary  area,  especially  in  the  case  of  anaemic 
murmurs;  and  this  probably  arises  (as  Naunyn  has  pointed 
out)  because  the  sonorous  vibrations  in  the  auricle  are  con- 
ducted into  the  auricular  appendix,  and  become  most  audi- 
ble at  that  point  on  the  chest-wall  where  the  appendix  ap- 
proaches nearest  to  the  surface — ?>.,  about  an  inch  and  a  half 
to  the  left  of  the  pulmonary  area. 

Mitral prcesystolic  and  diastolic  murmurs  arise  from  the  same 
cause,  viz. — stenosis  (narrowing)  of  the  mitral  orifice.  Im- 
mediately after  the  ventricles  of  the  heart  have  contracted 
they  relax  and  begin  to  refill  with  blood,  and  during  the 
period   of   time   represented   by   the  second    or    diastolic 


92  '       MEDICAL   DIAGNOSIS. 

sound,  and  by  the  long  pause,  this  process  of  filling  goes 
on.  At  first  the  blood  follows  the  retreating  walls  of 
the  ventricles,  propelled  partly  by  gravity  and  partly 
by  the  ordinary  intra-thoracic  pressure,  and  so  flows 
slowly  through  the  patent  orifices  (mitral  'and  tricus- 
pid) into  the  respective  ventricular  cavities.  But  toward 
the  end  of  the  long  pause  the  auricular  connection  takes 
place,  and  the  remainder  of  the  blood  is  thus  more  power- 
fully forced  into  the  ventricles.  In  ordinary  circumstances 
these  actions  take  place  noiselessly;  but  when  stenosis  of 
the  mitral  orifice  arises  (we  Speak  now  of  the  left  side  of 
the  heart  alone)  as  a  result  of  endocarditis,  the  narrowing 
may  be  sufficient  to  throw  the  fluid  into  sonorous  yibra- 
tions.  It  depends  on  the  rapidity  of  flow,  and  the  narrow- 
ness of  the  orifice  in  relation  to  the  size  of  the  ventricular 
cavity,  whether  or  not  a  murmur  will  occur — if  so  whether  it 
will  be  diastolic  or  praesystolic  in  rhythm,  or  in  other  words, 
whether  it  will  be  produced  when  the  blood  is  flowing  into 
the  ventricle  immediately  after  the  ventricular  systole,  or 
later  on,  during  the  auricular  systole. 

These  murmurs  sometimes  coexist,  and  may  either  run 
into  one  another,  and  so  fill  up  the  whole  time  occupied  by 
the  ventricular  diastole,  or  the)^  may  be  separated  by  a  very 
short  interval  of  silence.  The  diastolic  portion  is  usually 
soft,  whilst  praesystolic  (or  auricular-systolic)  murmurs  are 
almost  invariably  rough  in  character. 

Tricuspid  murmurs  resemble  those  at  the  mitral  valve  in 
regard  to  their  causation. 

Systolic  tricuspid  inurmurs  are  indicative  of  incompetence 
of  the  valve,  with  consequent  regurgitation  of  blood  into  the 
right  auricle  during  the  ventricular  systole.  This  results 
either  from  deformity  of  the  valve,  produced,  as  in  the  case 
of  the  mitral  valve,  by  endocarditis,  or  from  dilation  of  the 
orifice.  The  latter  condition  may  be  occasioned  by  such 
causes.as  produce  a  corresponding  state  of  matters  on  the 
left  side  of  the  heart  (fevers,  anaemia,  etc.),  but  more  com- 
monly this  relative  incompetence,  as  it  has  been  called,  is 
caused  by  distension  of  the  i-ight  auricle  and  ventricle,  the 
result  of  obstruction  to  the  circulation  through  the  lungs, 
produced  most  markedly  in  stenosis,  or  incompetence  of 
the  mitral  valve. 

Prcesystolic  tricuspid  murmurs  are  very  rarely  met  with,  and 
never  without  other  valvular  complications.  They  are  the 
result  of  stenosis  of  the  tricuspid  orifice,  and  the  mechanism 


CIRCULATORY   SYSTEM.  93 

of  their  production  is  similar  to  that  which  produces  the 
corresponding  mitral  murmur. 

Aortic  murmurs  are  of  two  varieties — systolic  and  dias- 
tolic.    These  usually  coexist. 

Systolic  aortic  viurmurs  are  those  produced  at  the  aortic 
orifice  as  the  blood  is  propelled  into  the  aorta  by  the  con- 
traction of  the  left  ventricle.  Such  a  murmur  arises  when 
the  orifice  is  contracted  or  roughened  as  a  result  of  endo- 
carditis. The  murmur  is  usually  loud  and  sawing,  occa- 
sionally musical,  and  whilst  it  is  loudest  in  the  aortic  area, 
it  can  most  frequently  be  heard  over  the  whole  front  of  the 
heart. 

Diastolic  aortic  murmurs  are  the  result  of  incompetence 
of  the  aortic  valves,  the  blood  regurgitating  from  the  aorta 
into  the  left  ventricle  during  the  ventricular  diastole.  The 
position  of  maximum  intensity  of  this  murmur  varies  very 
much.  In  many  cases  it  is  best  heard  in  the  aortic  area; 
not  uncommonly  it  is  loudest  at  the  ensiform  cartilage; 
rarely  the  apex-beat  is  the  situation  at  which  it  is  most  dis- 
tinct. 

Most  usually  these  two  murmurs  are  heard  together,  the 
so-called  double  aortic  murmur,  for  the  valves  are  rarely 
incompetent  without  presenting  some  obstruction  to  the 
flow  of  blood  over  them  into  .the  aorta. 

Pulmofiary  murrnurs. — Among  these  we  do  not  include 
those  haemic  murmurs  which  arise  at  the  mitral  valve,  and 
have  their  seat  of  greatest  intensity  an  inch  or  more  to  the 
left  of  the  pulmonary  area. 

True  pulmonary  murmurs  are  of  very  rare  occurrence. 
They  are  systolic  and  diastolic  in  rhythm. 

Systolic  ptilmonary  murmurs  are  either  inorganic  or  or- 
ganic. The  former  have  been  supposed  by  Quincke  to  be 
produced  where  from  some  cause  the  left  lung  is  retracted, 
and  the  heart  in  its  systole  so  compresses  the  pulmonary 
artery  as  to  give  rise  to  sonorous  waves  in  that  vessel. 

Organic  systolic  murmurs  are  almost  invariably  due  to 
congenital  constriction  of  the  pulmonary  artery.  Such 
cases  are  rare,  and  differ  much  from  one  another  according 
to  the  period  of  cardiac  development  at  which  the  constric- 
tion commenced.  The  ventricular  septum  is  usually  defi- 
cient, with  cyanosis  as  a  consequence. 

Diastolic  pulmonary  7nur7nurs  are  still  more  rare.  They 
result  from  incompetence  of  the  pulmonary  valves,  and  are 
invariably  accompanied  by  systolic  pulmonary  murmurs. 


94  MEDICAL  DIAGNOSIS. 

2.  Endocardial  murmurs  of  non-valvular  origin  are  prob- 
ably of  very  rare  occurrence  indeed.  They  may  result 
from — 

(i.)  Congenital  deficiency  of  some  part  of  the  septum, 
which  divides  the  two  sides  of  the  heart ;  and  in  that  case 
they  only  intensify  the  valvular  murmurs  already  existing. 

(2.)  Flakes  of  lymph  attached  to  the  valves  are  said  to 
cause  such  murmurs. 

(3.)  Changes  in  the  density  of  the  blood  in  anaemia,  chlo- 
rosis, etc.,  may  allow  of  murmurs  forming  under  conditions 
under  which  no  such  sonorous  vibrations  would  arise  in 
blood  of  normal  composition.  It  has  been  already  pointed 
out  that  many  of  the  hsemic  murmurs  are  mitral  in  their 
origin,  resulting  from  incompetence  caused  by  relaxation 
of  the  cardiac  muscle.  A  small  proportion  of  these  mur- 
murs may,  however,  arise  in  the  blood-stream,  where  no 
incompetence  exists.  Such  murmurs  are  soft,  invariably 
systolic,  and  usually  heard  most  distinctly  over  the  base  of 
the  heart. 

2.  Exocardial  Murmurs. — These  murmurs  are  caused  by 
the  friction  of  the  two  pericardial  surfaces  on  one  another, 
when  these  surfaces  have  become  roughened  as  a  result  of 
pericarditis,  etc.  Such  friction  murmurs  are,  for  the  most 
part,  readily  distinguished  from  endocardial  murmurs. 
They  are  rough  and  grating,  never  blowing.  They  are 
localized,  and  are  not  propagated  in  the  direction  of  the 
blood  current;  and  as  they  usually  arise  first  toward  the 
middle  of  the  heart,  the  point  of  greatest  intensity  does  not 
generally  coincide  with  any  one  of  the  cardiac  areas.  They 
can  always  be  perceived  by  the  hand,  if  at  all  intense,  which 
is  only  exceptionally  the  case  as  regards  endocardial  mur- 
murs. Further,  the  rhythm  of  exocardial  murmurs  is  ir- 
regular. They  are  not  confined  to  any  particular  phase  of 
the  cardiac  action,  are  neither  permanently  systolic  nor 
diastolic,  but  vary  from  minute  to  minute. 

Exocardial  murmurs  are  also  sometimes  occasioned  by 
friction  of  two  roughened  surfaces  of  the  pleura  overlying 
the  heart  on  one  another.  Such  friction  murmurs  vary  in 
intensity  with  the  movements  of  respiration. 


CIRCULATORY   SYSTEM.  95 


CHAPTER   XII. 

Circulatory   System — (continued). 

THE  EXAMINATION  OF    THE  ARTERIES  CAPILLARIES,  AND  VEINS. 

ARTERIES. 

The  physical  examination  of  the  arteries  may  be  con- 
ducted by  means  of  inspection,  palpation,  percussion  and 
auscultation.     Of  these  we  will  speak  in  their  turn. 

Inspection. — In  health  the  pulsation  of  the  arteries  of  the 
body  is  but  little  visible,  except  under  the  influence  of 
mental  emotion  or  bodily  strain.  As  the  result  of  disease, 
however,  pulsation  may  become  visible  in  all  the  super- 
ficial arteries  of  the  body,  particularly  in  the  carotid,  tem- 
poral, and  radial  vessels.  All  disturbances  of  cardiac  inner- 
vation, such  as  arise  in  Graves's  Disease,  and  all  feverish 
conditions,  are  liable  to  produce  such  excited  action  of  the 
heart  as  will  occasion  this  visible  pulsation.  Still  more 
marked  is  the  pulsation  when  the  left  ventricle  is  hyper- 
trophied,  and,  above  all,  when  the  aortic  valves  have  been 
rendered  incompetent.  Dilated,  tortuous,  and  visibly  pul- 
sating temporal  or  radial  arteries  are  usually  found  to  have 
undergone  atheromatous  changes  ;  and  finally,  inspection 
may  show  us  the  localized  pulsation  of  aneurism. 

Palpation  of  the  arterial  system  is  almost  confined  to  the 
radial  artery,  the  carotid,  brachial,  and  femoral  being  but 
rarely  palpated. 

The  radial  pulse  is,  in  health,  equal  on  the  two  sides;  but 
abnormal  distribution,  compression,  or  other  pathological 
condition  may  so  act  as  to  make  one  pulse  weaker  than  the 
other.  So,  also,  the  pulse-wave  propagated  from  the  heart 
outwards  toward  the  periphery  may  not  arrive  at  the  two 
wrists  synchronously.  This  condition  occurs  where  there  is 
simple  or  aneurismal  dilatation  of  the  aortic  arch,  and  is 
particularly  noticeable  if  the  aneurism  be  situate  between 
the  innominate  and  the  left  subclavian.  We  may  further 
notice  that  in  this  affection  the  interval  of  time  which  oc- 


96  MEDICAL  DIAGNOSIS. 

curs  between  the  cardiac  systole  and  the  arrival  of  the 
blood-wave  at  the  wrist  is  considerably  longer  than  usual. 
Such  delay  arises  either  from  stenosis  of  the  aortic  orifice 
rendering  the  systole  slow  and  difficult,  or  from  aortic  in- 
competence where  (as  Tripier  has  pointed  out  with  great 
probability)  the  onward  wave  meets  with,  and  is  delayed 
by,  the  regurgitating  blood. 

It  will  probably  conduce  to  greatest  clearness  if  the  con- 
ditions of  the  pulse  are  considered  under  three  headings — 
viz.,  (i)  frequency,  (2)  rhythm,  (3)  character. 

1.  Freqitcficy  of  the  pulse,  which  in  the  male  adult  averages 
about  seventy  beats  per  minute  (slightly  higher  in  women), 
varies  in  healthy  individuals  according  to  the  age,  accord- 
ing to  the  time  of  day,  the  external  temperature,  and  may 
be  greatly  influenced  by  mental  emotions  and  by  the  ad- 
ministration of  certain  drugs.  In  disease  the  pulse  is  some- 
times abnormally  slow,  as  for  example,  in  jaundice,  in  fatty 
degeneration  of  the  heart,  and  in  some  affections  of  the 
brain.  More  frequently,  however,  the  pulse  rate  is  increased 
in  rapidity.  The  rapid  pulse  of  fever,  of  collapse,  and  of 
the  various  cardiac  neuroses  is  well  known.  Very  generally 
the  pulse  is  rapid  in  diseases  of  the  valves  of  the  heart 
(particularly  the  mitral). 

2.  Rhythm. — The  radial  pulsations,  which  are  normally 
separated  by  regular  intervals  of  time,  and  so  are  rhythmi- 
cal, may  be  altered  in  this  relation  to  each  other  in  a  great 
variety  of  ways,  the  normal  rhythm  being  sometimes 
changed  into  total  irregularity;  while  at  other  times  the 
beats,  although  following  each  other  in  an  abnormal  man- 
ner, still  possess  a  certain  rhythm.  Amongst  the  latter 
may  be  mentioned  the  (i)  pulsus  bigeininus,  in  which  each 
two  beats  form  a  group  separated  from  the  two  which  pre- 
cede and  the  two  which  succeed  by  longer  pauses  than  the 
interval  which  separates  each  pair.  (2)  The  pulsus  para- 
doxus is  that  variety  of  pulse,  so  carefully  described  by 
Kussmaul,  where  with  each  inspiration  the  pulse-wave  be- 
comes smaller,  or  is  completely  lost.  When  it  is  present  in 
all  the  arteries  of  the  body,  it  may  be  due  to  one  of  two 
causes — either  to  fibrous  adhesions  between  the  aorta  and 
the  sternum,  or  some  other  obstruction  which,  during  in- 
spiration, prevents  the  free  passage  of  the  blood  into  the 
aorta;  or  it  may  result  from  any  obstruction  to  the  entrance 
of  air  into  the  lungs,  which  during  inspiration  lessens  the 
pressure   within    the   thorax.     When   the  pulsus  paradoxus 


CIRCULATORY   SYSTEM.  97 

occurs  only  in  one  radial  artery,  it  is  due,  as  Weil  has 
pointed  out,  to  inflammatory  adhesion  between  the  pleura 
and  the  subclavian  artery.  In  \.\\^ pulsus  alternans  there  is  a 
regular  alternation  between  a  small  and  a  large  pulsation. 
When,  after  a  series  of  regular  pulsations,  one  or  more 
beats  are  omitted,  the  pulse  is  said  to  be  intennitteiit.  These 
intermissions,  due  either  to  momentary  cessation  of  the 
heart's  action  or  to  the  blood-wave  in  question  being  too 
feeble  to  reach  the  wrist,  may  be  regular  or  irregular,  and 
often  occur  independently  of  heart  disease.  Most  frequently, 
however,  the  intermittent  pulse  is  associated  with  some 
cardiac  affection,  generally  mitral  disease.  Very  irregular 
pulsations,  in  which  no  rhythm  of  any  kind  can  be  detected, 
are  commonly  (although  by  no  means  always)  due  to  affec- 
tions of  the  mitral  valve,  generally  to  mitral  constriction, 
of  which  affection  an  extremely  irregular  pulse,  even  in  the 
early  stages,  is  an  important  symptom,  and  one  to  which 
considerable  diagnostic  importance  may  attach. 

3.  The  character  of  the  ptdse  varies  in  a  great  number  of 
ways,  giving  rise,  especially  in  the  works  of  the  older 
writers,  to  a  very  extensive  nomenclature.  It  will  be  suf- 
ficient for  ordinary  purposes  to  notice  the  following  points: 

(^.)  The  expansion  of  the  pulse.  A  pulse  which  reaches 
its  full  expansion  quickly,  and  as  rapidly  collapses  again, 
giving  to  the  finger  the  impression  of  a  very  quick  stroke, 
is  denominated  tht pulsus  celer,  and  this  celerity  is,  as  Cor- 
rigan  first  pointed  out,  most  distinct  where  there  is  aortic 
incompetence  (hence  called  Corrigan's  pulse).  The  opposite 
condition,  the  pulsus  tardus,  is  distinguished  by  the  slow 
manner  in  which  the  artery  fills  and  empties,  and  this  slug- 
gishness may  be  due  to  slowness  in  the  contractions  of  the 
heart,  to  a  hindrance  in  the  capillary  and  venous  circulation, 
or  to  loss  of  elasticity  in  the  arterial  wall  itself.  It  is  per- 
haps most  frequently  met  with  as  a  result  of  arterial 
sclerosis. 

{b.)  The  tension  of  the  pulse,  or,  in  other  words,  the  blood- 
pressure  on  the  inner  surface  of  the  artery,  may  be  approx- 
imately estimated  by  the  pressure  of  the  finger  required  to 
obliterate  the  pulse.  When  the  tension  is  high  (as  in  hy- 
pertrophy of  the  left  ventricle,  lead  colic,  peritonitis,  etc.), 
we  speak  of  a  hard  or  te?ise  pulse,  and  under  the  reverse  cir- 
cumstances (as  in  mitral  disease),  of  a  soft  and  compressi- 
ble pulse.  Above  all  things,  however,  it  must  be  borne  in 
mind  that  the  impression   of  tension  or  hardness  may  be 


98  MEDICAL  DIAGNOSIS. 

given  to  the  finger  by  a  rigid  condition  of  the  arterial  wall, 
and  it  is  only  when  this  factor  can  be  eliminated  that  any 
safe  deductions  can  be  drawn  regarding  the  blood-pressure 
itself.  When  the  radial  artery  has  undergone  calcification, 
the  irregular  prominences  can  usually  be  felt,  and  this  will 
prevent  error.* 

(c)  The  volimie  of  the  pulse.  A  full  pulse  may  be  pro- 
duced by  one  or  more  of  three  factors:  powerful  ventricu- 
lar contraction,  loss  of  elasticity  of  the  arterial  well,  andin- 
.terference  with  the  blood  flow  from  the  arteries  into  the 
capillaries.  The  opposite  conditions  may  give  rise  to  an 
empty  pulse.  The  pulse  is  also  spoken  of  as  large  or  small, 
tremulous,  thready,  etc. 

All  these  varieties  of  pulse  are  best  studied  with  aid  of 
the  sphygmograph. 

Percussion  of  the  Arteries  is  almost  entirely  limited  to 
cases  of  thoracic  aneurism,  of  which  mention  has  been  al- 
ready made. 

Auscultation  of  the  Arteries. 

I.  In  Health. — As  in  cardiac  auscultation,  so  also  in  aus- 
cultation of  the  arteries,  we  have  to  distinguish  two  phe- 
nomena— sounds  and  murmurs.  In  health,  if  the  stetho- 
scope be  placed  over  the  carotid  artery  as  lightly  as  possi- 
ble, two  sounds  are  usually  to  be  heard,  corresponding 
respectively  to  the  expansion  and  contraction  of  the  artery. 
Of  these  the  latter  is  simply  the  second  aortic  sound  con- 
ducted into  the  carotid,  and  it  seems  most  probable  (Weil, 
Heynsiusf )  that  the  sound  coinciding  with  the  arterial  ex- 
pansion ought  also  to  be  regarded  as  the  conducted  aortic 
systolic  sound  (Guttmann,J  however,  regards  it  as  in  part 
originating  in  vibrations  of  the  arterial  wall).  These  two 
sounds  can  also  generally  be  heard  in  the  subclavian;  and 
occasionally  the  first  can  also  be  detected  in  the  abdominal 
aorta,  the  brachial,  and  the  femoral;  but  in  the  more  peri- 
pheral vessels  no  auscultatory  phenomenon  is  present  in 
health.  If  pressure  be  made  with  the  stethoscope  upon  an 
artery,  such  as  the  brachial  just  above  the  elbow,  where 
normally  no  sound  can  be  heard,  the  narrowing  of  the  lu- 
men of  the  vessel  thereby  occasioned  gives  rise  to  vibrations 

*  The  tension  may  be  more  accurately  estimated   by  means  of  the 
sphygmomanometer  of  Von  Basch,  which  will  be  hereafter  described. 
\  Loc,  cit.  \  Lehrb.  der  Untersuchungs  Methods. 


r  CIRCULATORY   SYSTEM.  99 

in  the  blood  stream,  and  to  an  audible  murmur  coincident 
with  the  arterial  expansion.  If  the  pressure  be  increased, 
this  murmur  passes  into  a  sharp  sound. 

2.  In  Disease. — Sounds  or  murmurs  may  be  heard  in  the 
arteries  under  three  pathological  conditions: 

(<7.)  Murmurs  cofiducted  from  the  Heart.  —  It  is,  as  a  rule, 
aortic  murmurs  (both  systolic  and  diastolic)  which  are  pro- 
pagated into  the  arteries,  although  mitral  murmurs  are  oc- 
casionally to  be  heard  very  faintly  in  the  carotids. 

(^)  Sou7ids  a?td  Murmurs  originating  i7i  the  Arteries  in  con- 
sequence of  general  Circulatory  Disease. — In  aortic  incompe- 
tence a  sound  coinciding  with  the  arterial  expansion  may 
be  heard  in  all  the  accessible  arteries  of  the  body,  due  al- 
most certainly  to  the  rapid  transition  from  extreme  relaxa- 
tion to  extreme  tension  which  the  arterial  coats  then  un- 
dergo. A  double  sound  over  the  femoral  artery  is  also 
sometimes  to  be  heard  in  such  cases,  as  was  first  pointed 
out  by  Conrad,*  and  subsequently  more  fully  studied  by 
Duroziez,f  Traube,J  Friedreich, §  and  others,  and  lately  by 
Senator.il  The  first  of  these  sounds,  that  coinciding  with 
the  arterial  expansion,  originates  in  the  arterial  coats,  as 
already  described;  and  the  second  arises,  in  the  majority 
of  cases,  not  in  the  artery,  but  in  the  femoral  vein,  as  a  re- 
sult of  coexisting  tricuspid  incompetence.  Very  rarely,  in- 
deed, cases  occur  in  which  later  sounds  are  of  arterial  origin 
(the  tricuspid  valve  being  intact),  and  these  result  from 
aortic  incompetence. 

A  double  murmur  may  be  produced  in  the  femoral  artery 
in  cases  of  aortic  incompetence  by  pressure  with  the  stetho- 
scope, the  one  murmur  being  caused  by  the  pulse  wave,  the 
other  by  the  returning  backward  wave,  which  in  such  cases 
flows  towards  the  heart  during  the  arterial  collapse.  This 
double  murmur  may  also  occasionally  be  heard  in  cases  of 
anaemia,  typhoid  fever,  etc. 

(^.)  Murmurs  originating  in  the  Arteries  in  consequence  of 
Local  Changes. — Such  murmurs  are  to  be  heard  over  aneu- 
risms and  vascular  tumors,  but  more  important  are  the  sub- 
clavian murmurs.  While  occasionally  occurring  in  healthy 
persons,  murmurs  over  the   subclavian   arteries   are   much 

*  Zur  Lehre  iiber  die  Auskultation  der  Gefdsse.     Giessen,  i860. 

\  Arch.  gen.  de  mM.,  1861. 

X  Vide  Bert.  kl.   Woch,  1867,  No.  44. 

kDeutsches  Arch,  fur  kl.  Med.,  xxi.  p.  205.,  and  xxix.,  1881. 

\Zeitschr.f.  kl.  Med.,  iii.,  1881. 


100  MEDICAL  DIAGNOSIS. 

more  frequently  heard  incases  of  phthisis,  due  probably  to 
adhesions  between  the  pleura  and  the  vascular  walls,  and 
hence  much  influenced  by  the  respiratory  movements. 

The  encephalic  murmur  which  Fisher  discovered  in  chil- 
dren has,  so  far  as  our  present  knowledge  goes,  no  diagnos- 
tic significance. 

The  cephalic  murmur  which  Tripier  has  recently  shown 
to  be  present  in  anaemia  over  the  mastoid  process,  the  occi- 
put, and  the  eyeball,  is  supposed  by  him  to  be  of  arterial 
origin.  It  is  coincident  with  the  expansion  of  the  arteries; 
but  it  is  a  little  difficult  to  see  why,  if  it  be  an  arterial  mur- 
mur, it  should  be  loudest  in  these  three  positions,  and  hence 
Gibson  has  referred  it  to  vibrations  in  the  internal  jugular 
vein  produced  by  the  systolic  stroke  of  the  neighboring 
carotid  artery,  and  conducted  into  the  venous  sinus.  This 
ingenious  explanation  does  not,  however,  seem  to  me  satis- 
factory. I  am  inclined  to  regard  this  cephalic  murmur  as 
venous,  but  as  the  product  of  the  systolic  augmentation  of 
the  venous  current  which  takes  place  within  the  skull,  and 
within  the  eyeball,  due  to  the  fact  that  in  each  case  we  are 
dealing  with  a  closed  box,  which  is  practically  incapable  of 
expansion.  Hence,  when  a  sudden  increase  of  arterial  blood 
takes  place  in  them,  when  the  arteries  are  distended,  an 
equally  sudden  outflow  must  occur  through  the  veins.  To 
the  vibrations  in  this  sudden  venous  current  I  am  inclined 
to  ascribe  this  very  interesting  cephalic  murmur.  The 
watery  condition  of  the  anaemic  blood  is,  of  course,  the  im- 
portant factor. 

Capillaries. 

The  state  of  the  capillary  vessels  need  not  be  specially 
noticed  here,  seeing  that  the  more  noteworthy  points  have 
been  elsewhere  discussed. 

Veins. 

Knowledge  concerning  the  condition  of  the  veins  may  be 
obtained  by  inspection  and  by  auscultation.  Palpation  by 
the  fingers,  and  percussion,  are  not  fitted  materially  to  aid 
the  physician. 

Inspection. — By  inspecting  the  veins  we  ascertain,  firstly, 
their  state  as  to  fulness,  and  secondly,  whether  the  blood 
contained  in  them  undulates  or  pulsates. 


CIRCULATORY   SYSTEM.  lOI 

Overfilling  of  the  veins  results  either  from  local  obstruc- 
tion, when  the  vein  becomes  tense  on  the  distal  side,  and 
such  of  the  collateral  branches  as  are  not  compressed  en- 
large so  as  to  carry  on  the  circulation,  or  from  interference 
with  the  venous  circulation  generally.  Examples  of  the 
variety  of  engorgement  arising  from  local  obstruction  are 
to  be  found  in  cases  of  thrombosis  of  any  of  the  larger 
venous  trunks,  or  where  the  pressure  of  an  aneurism  or 
other  mediastinal  tumor  gives  rise  to  overfilling  of  the 
veins  of  the  arm.  The  distension  of  the  cervical  veins 
which  arises  where  the  general  circulation  is  interfered 
with  has  already  been  described. 

Undidatloji  of  the  Veins  of  the  Neck. — The  pulsations  in  the 
cervical  veins  which  correspond  to  the  movements  of  the 
heart  have  been  already  remarked  upon.  It  only  remains 
to  mention  the  undulation  which  the  respiratory  move- 
ments sometimes  produce  in  the  jugular  veins.  When  the 
cervical  veins  are  overfilled  as  a  result  of  pulmonary  em- 
physema, or  of  mitral  stenosis,  each  inspiration  diminishes 
the  venous  distension,  while  each  expiration  increases  it, 
and  so  the  veins  show  a  constant  undulation. 

Auscultation. — Although  in  cases  of  tricuspid  incompe- 
tence systolic  sounds  are  occasionally  to  be  heard  over  the 
jugular  and  femoral  veins,  the  only  auscultatory  sign  which 
here  demands  attention  is  the  humming  murmur,  the  so- 
called  bruit  de  diable  which  is  very  frequently  to  be  heard  in 
chlorotic  females  over  the  bulb  or  dilatation  of  the  internal 
jugular  vein,  and  more  rarely  over  the  large  intrathoracic 
venous  trunks,  the  superior  vena  cava,  and  the  innominatic 
veins.  Venous  murmurs  in  the  former  are  best  heard  at 
the  right  border  of  the  sternum,  from  the  first  right  inter- 
costal space  to  the  third  costal  cartilage.  The  murmur  in 
the  right  innominate  vein  is  usually  loudest  at  the  sternal 
end  of  the  first  right  costal  cartilage,  and  that  in  the  left 
over  the  manubrium  sterni.  Occasionally  a  venous  hum  is 
to  be  heard  in  dilated  thyroid  veins,  and  in  the  subclavians, 
axillary,  brachial,  and  femoral  veins.  In  venous  ausculta- 
tion, it  must  be  borne  in  mind  that  the  slightest  unneces- 
sary pressure  with  the  stethoscope  may  develop  an  artificial 
murmur. 

The  bruit  de  diable.,  as  met  with  in  the  jugular  vein  (gene- 
rally loudest  on  the  right  side),  is  usually  of  a  continuous 
soft  humming   character,   and   occurs   very   frequently  in 


102  MEDICAL  DIAGNOSIS. 

health.  Winterich  *  detected  it  in  80  per  cent  of  the  Bava- 
rian cuirassiers  whom  he  examined.  Only  when  the  mur- 
mur is  strong  and  loud  is  it  pathological,  or  can  it  be  taken 
as  evidence  of  the  existence  of  anaemia;  and  we  may,  with 
Friedreich,!  define  the  pathological  venous  murmur  as 
limited  to  those  cases  in  which  a  thrill  is  perceived  when 
the  finger  is  applied  over  the  jugular  bulb,  or  in  which  the 
murmur  is  sufficiently  loud  to  be  heard  when  the  ear  is  re- 
moved a  little  way  from  the  stethoscope,  or  to  become  ap- 
parent to  the  patient  himself,  and  finally,  when  a  murmur 
can  be  perceived  over  the  intrathoracic  venous  trunks. 

These  venous  murmurs  appear  to  depend  for  their  pro- 
duction upon  three  factors — ist,  upon  the  rapidity  of  the 
blood  current;  2d,  upon  the  change  in  the  calibre  of  the 
vein  at  any  particular  point  (such  as  occurs  in  a  marked 
manner  at  the  jugular  bulb);  and  3d,  upon  alteration  in  the 
quality  of  the  blood,  whether  this  consists  in  an  actual  or 
only  a  relative  increase  of  the  watery  elements. 

Usually  the  jugular  humming  murmurs  are  continuous, 
but  they  very  often  vary  in  intensity,  and  occasionally  are 
actually  intermittent.  They  are  influenced  in  the  following 
ways: 

1.  Changes  in  the  Posture  of  the  Patient. — When  the  head 
is  turned  to  the  opposite  side  the  murmur  becomes  much 
intensified,  owing  to  the  compression  of  the  vein  by  the 
muscles  and  fascia.  Even  when  no  murmur  exists  when 
the  head  is  held  straight,  a  faint  bruit  may  be  developed 
when  the  head  is  rotated;  especially  if  firm  pressure  be 
made  wath  the  stethoscope  in  addition. 

Owing  to  the  acceleration  of  the  blood  flow  in  the  veins 
the  murmur  is  louder  when  the  patient  sits  or  stands  than 
in  the  recumbent  posture. 

2,  The  Move7nents  of  Respiration. — Sometimes  the  venous 
murmur  in  the  jugular  is  only  audible  during  deep  inspira- 
tion, and  if  it  be  continuous  it  is  almost  invariably  intensi- 
fied by  that  action,  in  both  cases,  for  this  reason — viz.,  that 
during  inspiration  the  flow  of  blood  in  the  vein  is  acceler- 
ated. The  same  usually  holds  good  with  regard  to  mur- 
murs in  the  femoral  vein,  although  in  rare  instances  the 
reverse  obtains,  and  we  meet  with  the  remarkable  phenom- 


*  Deutsche  Klinik,  1850. 

f  Deutsch.  Arch.  f.  kl.  Med.,  vol.  xxix.  (1881)  p.  263. 


CIRCULATORY   SYSTEM.  103 

enon  of  a  femoral  murmur  which  is  expiratory  in  rhythm,* 
this  probably  resulting  from  the  increased  abdominal  pres- 
sure which  the  descent  of  the  diaphragm  occasions,  and 
which  retards  the  blood  current  in  the  femoral  vein. 

3.  The  Movements  of  the  Heart. — The  anaemic  murmur  in 
the  jugular  vein  is  sometimes  diastolic  in  rhythm,  as  was 
first  pointed  out  by  Chauveau,f  who  ascribed  it  to  the  in- 
creased blood  current  in  the  vein  which  is  the  result  of  the 
diminution  of  pressure  in  the  superior  vena  cava  produced 
during  diastole,  and  which  stands  closely  related  to  the 
negative  diastolic  pressure  in  the  ventricle.  While  this  is 
no  doubt  one  cause  of  this  diastolic  venous  hum,  it  appears 
to  the  author  extremely  probable  that  the  cause  suggested 
by  Friedreich  is  likewise  operative — viz.,  that  the  pulsa- 
tions of  the  aorta  compress  the  superior  vena  cava  during 
the  cardiac  systole,  thus  allowing  an  uninterrupted  flow  of 
venous  blood  during  diastole. 


CHAPTER  XIII. 

Circulatory  System — {Continued), 

GRAPHIC    CLINICAL    METHODS. 

When  Chauveau  and  Marey  first  introduced  to  the  notice 
of  the  profession  the  sphygmograph  and  cardiograph,  it 
was  hoped  that  a  new  and  more  accurate  examination  of 
the  heart  and  circulatory  system  would  soon  replace  the 
former  methods.  This  hope  has  not  been  realized.  There 
is,  indeed,  little  difficulty  in  obtaining  tracings  of  the  pulse 
wave  and  heart  beat,  and  these  tracings,  moreover,  are 
found  to  vary  greatly  in  different  diseases;  but  the  true 
meaning  of  these  differences  is  as  yet  by  no  means  thor- 
oughly understood.  The  reason  for  this  lies  partly  in  the 
fact  that  the  meaning  of  the  normal  pulse  and  heart  curve 
has  not  yet  been  explained,  in  all  its  details,  in  a  fully  satis- 
factory manner.  Still,  even  now,  certain  trustworthy  facts 
can  be  obtained  by  the  use  of  the  recording  instruments 
referred  to,  and  the  number  of  these  facts  will  necessarily 
increase  as  the  characteristics  of  the  normal  pulse  wave  and 

*  Friedreich,  loc.  cit.  \  Gaz.  MM.  de  Paris,  1858. 


104  MEDICAL  DIAGNOSIS. 

heart  beat  and  the  modifications  which  they  may  undergo 
in  health  become  more  fully  understood.  Moreover,  the 
permanence  of  the  records  which  may  be  obtained  by  the 
use  of  such  instruments,  their  value  in  illustrating  the 
history  of  individual  cases,  together  with  the  fact  that  these 
instruments  give  results  which  are  more  purely  objective 
than  those  obtainable  by  other  methods,  amply  justify  a 
somewhat  full  description  of  the  manner  of  using  the 
sphygmograph  and  cardiograph,  together  with  some  ac- 
count of  the  results  obtainable  by  their  help. 

Sphygmograph. — The  original  instrument  of  Chauveau 
and  Marey  which,  since  its  introduction,  has  been  re- 
peatedly modified  in  detail  by  Marey  himself  and  by  others, 
in  its  present  form  (as  supplied  by  Breguet)  is  the  most 
favorite  form  of  instrument  employed  at  the  present  day. 
Some  have  sought  to  introduce  the  so-called  transmission 
sphygmograph,  but  it  seems  to  be  generally  accepted  that 
the  advantages  which  this  form  of  instrument  presents  in 
certain  particulars  are  more  than  counterbalanced  by  very 
obvious  defects.  All  of  these  transmission  sphygmographs 
are  similar  in  principle,  consisting  of  two  closed  Marey's 
tambours — one  being  influenced  through  the  medium  of  a 
button  pressing  on  the  radial  artery,  while  the  second 
tambour,  joined  to  its  fellow  by  an  india-rubber  tube,  is 
arranged  to  move  a  recording  lever  which  w^rites  on  the 
blackened  surface  of  a  revolving  cylinder.  The  great  ad- 
vantage presented  by  this  form  of  sph3'gmograph  is  that 
by  its  means  we  can  obtain  curves  of  practically  indefinite 
length,  more  especially  if  the  revolving  cylinder  move 
round  a  spiral  spindle.  On  the  other  hand,  these  instru- 
ments are  all  more  or  less  cumbersome  and  expensive,  while 
the  introduction  of  a  long  column  of  air  to  transmit  the 
form  of  the  pulse  wave  to  the  recording  lever  introduces 
many  serious  possible  errors.  However,  for  investigation 
of  certain  special  points,  as,  for  example,  where  simultane- 
ous tracings  of  the  pulse,  heart,  and  respiratory  movements 
are  desired,  the  transmission  sphygmograph  is  the  only 
instrument  which  can  be  employed.  Of  these  Marey's 
polygraph  *  is  probably  the  most  perfect  and  convenient. 

On  account  of  its  comparatively  small  cost  and  conven- 
ient size,  it   is  probable   that   the   original  Chauveau  and 

*  Vide  Marey,  La  Circulation  du  sang  a  V^tat  physiologique  et  dans  Us 
Maladies.     Paris,  i88i. 


CIRCULATORY   SYSTEM. 


105 


Marey's  sphygmograph,  in  its  most  recent  modification,  will 
still  continue,  at  least  for  some  time,  to  be  the  most  com- 
monly used  instrument.  The  principle  of  its  construction 
is  to  be  found  in  all  text-books  of  physiology,  and  need  not 
therefore  be  dealt  with  here;  and  I  will  confine  myself  to  a 
description  of  the  typical  pulse  curve,  and  the  modifications 
which  it  undergoes  in  health  and  in  disease. 

The  typical  healthy  curve,  of  which  the  accompanying  trac- 
ing (Fig.  i)  is  an  example,  is  usually  divided  into  an  as- 
cending and  descending  portion,  either  or  both  of  which 
may  present  certain  secondary  undulations.  In  its  most 
typical  form  (as  in  Fig.  i)  the  ascending  line  [a  to  h)  rises 
abruptly  at  first,  and 
afterwards  more  slowly, 
till  it  reaches  its  highest 
point.  Then  descending 
more  obliquely,  it  usu- 
ally presents  a  more  or 
less  well-defined  notch  or 
indenture  {c)  before  it 
reaches  the  principal 
notch  or  valley  (^).  This 
latter  notch  is  best  known 
as  the  dicrotic  notch,  and 
is  of  great  importance, 
corresponding  as  it  does 
exactly  to  the  closure  of 

the  aortic  valves.  After  the  dicrotic  notch,  the  curve 
describes  a  slight  elevation  before  descending  to  its  lowest 
level,  in  the  course  of  which  descent  a  low  wave-like 
eminence  (/)  is  not  unfrequently  to  be  discovered.  Since 
the  point  (a)  corresponds  to  the  opening  of  the  aortic 
valves,  and  the  point  (^)  to  their  closure,  the  artery  is, 
during  the  time  represented  by  the  interval  between  these 
two  lines,  in  free  communication  with  the  interior  of  the 
ventricle,  while,  during  the  time  of  the  rest  of  the  curve  the 
artery  is  cut  off  from  the  heart. f     The  point  d^  therefore, 

*  For  this  curve  and  those  which  follow,  as  well  as  for  much  help  and 
advice  in  the  preparation  of  this  chapter,  I  am  indebted  to  the  kindness 
of  my  friend  Dr.  C.  S.  Roy,  of  the  Brown  Institute,  whose  surpassing 
skill  in  instrumentation  is  well  known. 

\  The  whole  pulse  wave  is  delayed  in  its  transmission  from  the  com- 
mencement of  the  aorta  to  the  radial  artery,  but  the  delay  of  the  differ- 
ent parts  of  the  curve  is  usually  tolerably  equal,  so  that  the  relative 
distance  between  the  up-stroke  and  the  dicrotic  notch  remains  the  same. 


Fig.  I.— Normal  Pulse  Curve.* 


I06  MEDICAL  DIAGNOSIS. 

forms  the  most  natural  division  of  the  pulse  wave  into  its 
more  fundamental  parts,  the  causes  which  influence  its 
form  during  the  first  half  being  essentially  different  from 
those  which  modify  the  second  half.  Keeping  this  fact  in 
view,  and  premising  that  it  is  almost  always  easy  to  find  in 
any  curves,  of  whatever  form  the  point  which  corresponds 
to  d  in  our  typical  curve,  I  now  proceed  to  describe  the 
modifications  of  the  pulse  wave  which  are  to  be  met  with. 

And,  first,  with  regard  to  changes  in  the  first  half  of  the 
curve. 

Anacrotic  Pulse. — The  typical  pulse  curve,  of  which  I  have 
given  an  example  above,  is  not  infrequently  called  dicrotic, 
owing  to  the  fact  that  it  presents  a  fairly  well-marked  notch 
in  its  descending  part,  although  some  authors  prefer  to 
restrict  the  term  dicrotism  of  the  pulse  wave  to  cases  in 
which  that  notch  is  abnormally  well  marked.  In  contra- 
distinction to  the  dicrotic  pulse,  it  is  the  custom  to  call 
those  pulse  waves  in  which  a  more  or  less  well-marked 
notch  occurs  in  the  ascending  line  as  anacrotic.  The  trac- 
ing (Fig.  2)  annexed  shows  a  fairly  typical  example  of  the 

anacrotic  pulse  wave.  It  can 
be  seen  that  it  differs  from  the 
dicrotic  or  normal  pulse-wave 
only  in  the  part  which  lies  be- 
tween the  lines  a  and  d;  in 
other  words,  in  that  part  of 
the  pulse  wave  which  corre- 
sponds to  the  time  when  the 
aortic  valve  is  open.  We 
would,  therefore,  expect,  a 
priori.,  that  this  change  in  the 

Fig.  2.— Anacrotic  Pulse  Wave.  form   of  that  part  of   the  pulse 

wave  must  be  due  to  some 
difference  in  the  relation  between  the  quantity  of  blood 
thrown  out  of  the  left  ventricle  and  the  elastic  resistance 
offered  by  the  aorta  and  larger  arteries.  Let  us  suppose 
that  the  arteries  are  relatively  lax,  and  that  the  quantity  of 
blood  thrown  out  of  the  ventricle  is  not  above  normal,  then 
it  is  not  difficult  to  understand  that  the  ventricle  will  more 
readily  and  more  rapidly  empty  itself  than  when  the  vessels 
are  relatively  rigid.  The  result  of  this  is  that  the  point  of 
the  pulse  wave,  where  the  highest  pressure  exists,  and 
which  corresponds  to  the  highest  point  of  the  pulse  curve, 
will  occur  nearer  its  commencement  than  would  otherwise 


CIRCULATORY   SYSTEM.  10/ 

be  the  case.  Let  us,  on  the  other  hand,  suppose  an  ex- 
treme case,  in  which  the  arteries  are  very  rigid,  as  in  well- 
marked  atheroma,  or  calcification  of  the  larger  vessels, 
these  latter,  as  the  contents  of  the  ventricle  are  forced  into 
them  during  systole,  do  not  expand  to  receive  the  contents 
of  the  ventricle,  but  act  more  like  rigid  tubes,  the  result  of 
which  is  that  during  the  cardiac  systole  the  inflow  into  the 
vessels,  which  is  always  greater  than  the  outflow  at  that 
period,  produces  a  continuous  rise  in  arterial  pressure  dur- 
ing the  whole  time  of  systole.  The  point  of  highest  pres- 
sure of  pulse  wave,  or,  in  other  words,  the  highest  part  of 
the  pulse  tracing,  is  thus  thrown  toward  the  end  of  the 
ventricular  part  of  the  pulse  curve,  or,  in  other  words, 
closer  to  the  dicrotic  notch,  d^  which  marks  the  end  of  the 
systole.  In  other  words,  in  cases  where  the  larger  arteries 
are  not  fitted  to  contain  the  quantity  of  blood  contained  in 
the  ventricle,  the  latter  forces  the  blood  at  first  against  a 
comparatively  weak  resistance,  which,  however,  goes  on  in- 
creasing very  rapidly  as  the  large  arteries  become  gradually 
more  and  more  tensely  filled;  and  the  pressure  within  these 
latter  necessarily  rises  from  the  commencement  to  the  end 
of  the  cardiac  systole.  This,  then,  is  the  reason  why,  in 
such  circumstances,  the  highest  part  of  the  pulse  curve  is 
nearest  our  line  d^  or  the  dicrotic  notch  which  corresponds 
to  the  end  of  the  ventricular  systole. 

I  have  as  yet  said  nothing  of  the  indenture  (c)  which  pre- 
cedes the  dicrotic  notch,  and  which,  on  that  account,  is 
usually  described  as  the  pre-dicrotic  notch.  The  exact 
significance  of  this  notch  is  still  by  no  means  so  fully 
understood  as  is  desirable.  It  would  seem  that  its  appear- 
ance results  from  the  fact  that,  at  the  moment  when  the 
aortic  valves  are  forced  open,  the  column  of  blood  con- 
tained in  the  aortic  arch  and  larger  branches  receives  a 
sudden  impulse  towards  the  periphery,  and  the  inertia  of 
this  column  of  blood,  thus  set  in  comparatively  rapid 
motion,  produces  a  negative  wave  at  the  commencement  of 
the  aorta,  which  is  propagated  towards  the  periphery  in  the 
same  manner  as  the  positive  wave  which  preceded  it.  I 
have  spoken  of  the  causes  which  may  theoretically  produce 
anacrotism,  and  also  the  probable  cause  of  the  pre-dicrotic 
notch,  and  must  now  proceed  to  refer  to  the  conditions 
under  which,  in  practice  at  the  bedside,  we  find  the  ventri- 
cular part  of  the  pulse  wave  so  modified. 

If  the  glottis  be  closed,  and  the  pressure  within  the  thorax 


Io8  MEDICAL  DIAGNOSIS. 

and  abdomen  be  raised  by  powerful  continuous  contraction 
of  the  respiratory  muscles,  we  produce  a  change  in  the  dis- 
tribution of  the  blood  in  the  arteries  and  veins.  The  intra- 
abdominal and  intra-thoracic  veins  are  relatively  empty, 
and  an  abnormally  large  quantity  of  blood  accumulates  in 
the  systemic  arteries.  During  this  state  the  arterial  walls 
are  more  or  less  powerfully  distended,  and,  following  known 
laws  regarding  arterial  elasticity,  they  are  in  that  condition 
more  rigid  than  when  their  calibre  is  normal.  Even  in 
tolerably  young  subjects,  by  this  means  we  can  easily  pro- 
duce artificially  an  anacrotic  pulse  wave,  the  arteries  being 
rendered  relatively  rigid  in  relation  to  the  quantity  of  blood 
which  is  forced  into  them  at  each  ventricular  contraction. 
This  arterial  engorgement  or  high  pressure,  only  temporary 
in  such  an  experiment,  is,  however,  lasting  in  certain  dis- 
eased conditions,  the  most  marked  of  these  being  the  ar- 
terial high  pressure  which  accompanies  certain  forms  of 
chronic  kidney  disease,  in  which  latter  case  the  conditions 
are  still  more  favorable  for  the  production  of  an  anacrotic 
pulse  wave,  seeing  that  not  only  are  the  arteries  abnor- 
mally rigid  from  the  distension,  but  also  that  the  quantity 
of  blood  forced  into  them  with  each  contraction  of  the 
ventricle  is  relatively  and  absolutely  great,  owing  to  the 
existence  of  eccentric  hypertrophy  of  the  left  ventricle. 
Analogous  conditions  occur,  as  already  indicated,  in  cases 
of  atheroma  or  calcification  of  the  larger  arteries,  such  as 
occur  in  old  age.  The  conditions,  therefore,  which  produce 
the  anacrotic  pulse  wave  are  in  practice  either  abnormal 
distension  of  the  larger  arteries,  accompanied  or  not  by  hy- 
pertrophy of  the  ventricle,  or  rigidity  of  the  arterial  w^alls 
due  to  changes  in  molecular  structure  of  their  middle  coats. 
The  more  marked  these  conditions  are,  the  more  is  the 
second  elevation  (c)  higher  than  the  first.  (^  in  Figs,  i  and 
2.)  In  practice,  all  imaginable  intermediate  forms  between 
the  typical  pulse  wave  of  health  and  the  typical  anacrotic 
pulse  wave,  as  in  Fig.  2,  are  encountered,  and  it  is  usually 
easy  in  each  individual  case  to  tell  from  the  other  phe- 
nom.ena  whether  the  anacrotism  be  due  to  simple  distension 
of  the  arteries  from  high  pressure,  to  molecular  change  in 
the  arterial  coats,  or  to  hypertrophy  of  the  heart.  From 
what  I  have  said  it  will  be  understood  that  although  the 
anacrotic  pulse  wave  very  often  means  an  abnormally  high 
arterial  pressure,  this  is  by  no  means  always  the  case.  Fi- 
nally, before  leaving  the  changes  confined   chiefly  or  en- 


CIRCULATORY   SYSTEM.  IO9 

tirely  to  what  I  have  named  the  ventricular  part  of  the 
pulse  wave,  a  word  may  be  said  regarding  the  conditions 
which  favor  the  appearance  of  a  well-marked  pre-diastolic 
notch.  The  condition  fitted  to  produce  this  notch  in  its 
most  marked  form  is  that  in  which  the  part  of  the  syste- 
mic arteries  nearest  the  heart  is  abnormally  rigid;  for  it 
need  scarcely  be  said  that  if  this  latter  part  of  the  systemic 
arterial  system  is  fairly  elastic,  it  will  contract  behind  the 
suddenly  impelled  first  wave,  and  prevent  more  or  less  com- 
plete!}" the  formation  of  a  negative  wave  or  tendency 
towards  a  vacuum  at  the  commencement  of  the  aorta. 

We  now  turn  to  consider  a  different  series  of  changes  in 
the  form  of  the  pulse  wave,  which  are  due  to  changes  in  the 
arterial  circulation  of  an  entirely  different  kind  from  those 
above  referred  to,  and  in  which  practically  invariably  the 
dicrotic  notch  is  abnormally  exaggerated. 

Abnormally  Dicrotic  Pulse  Waves.- — I  have  said  above  that 
on  closing  the  glottis  and  contracting  powerfully  the  respi- 
ratory muscles,  the  systemic  arteries  are  at  first  abnormally 
filled  with  blood;  this  abnormal  distension  very  soon,  how- 
ever, gives  place  to  an  abnormal  emptiness  of  these  vessels, 
owing  to  the  fact  that  the  pressure  on  the  intrathoracic 
veins  diminishes  the  quantity  of  blood  which  reaches  the 
vertricle,  the  result  being  that  the  blood  accumulates 
chiefly  in  the  veins  of  the  head  and  limbs.  The  artificial 
arterial  anaemia  so  produced  leads  to  a  characteristic 
change  in  the  form  of  the  pulse  wave,  which 
becomes,  as  in  Fig.  3,  smaller  in  size  and 
more  markedly  dicrotic  than  even  the  nor- 
mal pulse,  while  all  trace  of  anacrotism 
completely  disappears.  It  is  unnecessary 
for  us  to  go  minutely  into  the  theory  of  the 
production  of  the  abnormally  dicrotic  pulse 
wave.  For  practical  purposes  it  will  suffice 
to  refer  to  the  conditions  which  lead  to  the 
appearance  of  this  form  of  curve.  Roughly 
speaking,  these  may  be  said  to  consist  in 
abnormal  emptiness  of  the  arterial  system, 
such  as  is  produced,  for  example  (^),  by 
anaemia  after  venesection,  in  which  case  the  ^}'^-  s-^'^bnormaiiy 

,        ,  .  r  1  1         1    .        1  •         •     Dicrotic  Pulse  W  ave. 

absolute  quantity  of  blood  m  the  arteries  is 
diminished,  although  these  latter  contain  relatively  normal 
amount;  {p^  in  cases  of  unusual  expansion  of  the  arterioles 
and  capillaries  leading  to  a  relatively  rapid  outflow  from 


1 10  Medical  diagnosis. 

the  arteries,  as  in  the  condition  produced  by  amyl-nitrite 
inhalation;  or  finally,  dicrotism  may  be  produced  by  {c) 
diminution  in  the  quantity  of  blood  which  enters  the  aorta 
through  the  ventricle — the  most  marked  examples  of  which 
are  to  be  found  in  cases  of  uncompensated  mitral  regurgi- 
tation.* Such  are  the  conditions  which,  in  practice,  are 
found  to  produce  the  dicrotic  pulse  wave;  and  it  may  be 
noted  in  passing  that  simple  or  pure  dicrotic  pulse  wave 
invariably  results  from  abnormally  low  arterial  pressure, 
the  cause  of  which,  in  individual  cases,  it  is  rarely  difficult 
to  discover. 

Hyperdicrotic  is  the  term  applied  to  that  form  of  the  di- 
crotic pulse  in  which  the  dicrotic  notch  descends  lower  than 
the  commencement  of  the  systolic  rise.  This  is  due  to  the 
fact  that  each  successive  cardiac  systole  follows  its  prede- 
cessor before  the  pressure  within  the  artery  has  fallen  be- 
low that  which  it  presented  at  the 
dicrotic  notch.  This  form  of  curve 
(Fig.  4),  although  presenting  a  notch 
in  its  ascending  part,  is  due  to  entirely 
different  conditions  from  those  which 
produce  the  true  anacrotic  pulse 
wave,  with  which  it  can  never  in 
practice  be  confounded,  owing  to  the 
fact  that  the  rounded  smooth  emi- 
nences of  which  it  is  made  up  shows 
it  at  a  glance  to  be  of  the  dicrotic 
type;  it  is,  in  fact,  an  exaggerated 
dicrotic  pulse-wave. 
Fig.  4.-Hy^erfkrotic  Pulse       The  anacrotic  and  the  dicrotic  pulse 

waves  are  the  two  principal  simple 
modifications  which  are  met  with,  but  there  are  various 
intermediate  or  combined  pulse  waves  due  to  combination 
of  the  conditions  fitted  to  produce  the  anacrotic  and  the 
dicrotic  waves — for  example,  in  cases  of  aortic  regurgita- 
tion with  hypertrophied  ventricle,  the  first  or  ventricular 
part  of  the  curve  usually  is  of  the  true  anacrotic  type, 
while,  on  cessation  of  the  systole,  the  reflux  into  the  heart 
causes  more  or  less  powerful  negative  wave  producing  an 
abnormally  deep  dicrotic  notch.  In  addition  to  this,  the 
rapid  filling  of  the  comparatively  empty  arteries  with  each 

*  Not  unfrequently  two  or  more  of  these  causes  may  be  combined,  as 
happens  in  fevers. 


CIRCULATORY  SYSTEM.  HI 

ventriculatory  systole  leads  to  an  abnormally  steep  and 
high  ascending  limb  of  the  curve. 

We  have  given  the  conditions  which  lead  to  the  two  prin- 
cipal forms  of  pulse  wave  met  with  in  disease;  but,  as  I 
have  said,  all  possible  combinations  of  these  conditions  are 
constantly  occurring,  leading  to  some  less  well-defined  type 
of  pulse  curve.  Into  a  detailed  account  of  these  more  com- 
plicated pulse  curves  we  cannot  enter  here.  What  we  have 
already  said  will  enable  the  observer  to  understand  the 
meaning  of  each.  Examples  of  these  are  found  in  the  vari- 
ous modifications  of  pulse  curve  in  prolonged  fever  cases, 
in  the  early  stages  of  which  it  is  often  high,  bounding  with 
a  tendency  towards  the  anacrotic  type,  but  gradually  from 
day  to  day  becoming  more  and  more  dicrotic,  and  not  un- 
frequently  being  eventually  hyperdicrotic. 

Cardiograph. — The  results  w^hich  may  be  obtained  by  the 
use  of  the  cardiograph  are  on  the  whole  less  satisfactory 
than  those  of  the  sphygmograph.  This  is  in  part  due  to  the 
fact  that  none  of  the  instruments  at  present  in  use  for  re- 
cording the  contractions  of  the  human  heart  can  compare 
with  the  sphygmograph,  in  so  far  as  compactness  and 
accuracy  are  concerned.  While  some  observers,  such  as 
Landois,  have  attempted  to  record  the  form  of  the  apex 
beat  by  applying  to  the  surface  of  the  chest  the  sphygmo- 
graph of  Marey,  the  majority  of  the  instruments  employed 
at  the  present  day  are  transmission  instruments,  being  con- 
structed in  the  same  manner  as  the  transmission  sphygmo- 
graph, which  I  have  already  described.  It  is  extremely 
desirable  that  we  should  have  at  our  disposal  some  direct 
acting  cardiograph  similar  in  principle  to  the  sphymograph 
of  Chauveau  and  Marey.  Such,  however,  has  not  as  yet 
been  described.  In  the  meantime  the  transmission  cardio- 
graph is  the  one  which  is  almost  universally  employed. 
That  of  Burdon  Sanderson,*  or  the  polygraph  of  Marey,f 
are  amongst  the  best,  if  not  the  very  best.  I  need  not 
enter  upon  the  manner  of  using  these  and  similar  instru- 
ments, but  will  proceed  to  describe,  firstly,  the  typical  nor- 
mal heart  curve;  and  secondly,  the  principal  modifications 
which  it  may  present. 

Normal  Heart  Curve. — In  Fig.  5  is  represented  a  typical 


*  "  Handbook  of  the  Physiological  Laboratory,"  edited  by  Burdon 
Sanderson. 
f  Loc  cit. 


tI2 


MEDICAL  DIAGNOSIS. 


normal  curve  of  this  kind.  The  curve,  it  will  be  seen, 
immediately  after  rising  from  its  lowest  point  (/),  de- 
scribes a  more  or  less  well  marked  rounded  elevation  be- 
tween/and «,  and  from  a  it  ascends  at  first  rapidly,  after- 
wards somewhat  more  slowly,  to  its  highest  point  b,  from 
whence  it  describes  a  more  or  less  obliquely  descending, 
usually  undulating  line  to  e^  after  which  the  curve  descends, 
at  first  slowly,  then  more  rapidly,  and  finally  with  increas- 
ing slowness,  until  the  point /is  reached.  That  part  of  the 
curve  lying  between  /  and  «  corresponds  in  time  to  the  con- 


FiG.  5.— Normal  Heart  Curve. 

traction  of  the  auricles,  and  when  the  curve  is  taken  from 
the  apex,  the  elevation  between /and  a  is  due  to  the  more 
or  less  sudden  filling  of  the  ventricles  which  results  from 
the  auricular  contractions.  That  part  of  the  curve  lying 
between  the  lines  a  and  e  is  produced  during  the  time  of  con- 
traction of  the  ventricular  muscle,  while  the  part  from  e  to/ 
corresponds  with  the  passive  expansion  of  the  ventricular 
muscle.  In  so  far  as  the  ventricles  are  concerned,  we  may 
divide  the  whole  heart  curve  into  two  parts — viz.,  first,  that 
from  a  to  e,  during  which  the  ventricular  muscle  is  in  a  state 
of  contraction;  and  second,  that  from  e  to  a,  which  corfe- 


CIRCULATORY   SYSTEM.  II3 

ponds  to  the  ventricular  diastole.  The  sudden  rise  from 
<3!  to  (^  is  produced  by  the  tightening  of  the  ventricles  over 
their  contents,  and  the  point  b  corresponds  in  time  to  two 
important  phases  of  each  heart  beat — viz.,  first,  the  moment 
of  closure  of  the  auriculo-ventricular  valves;  and  secondly, 
the  moment  when  the  heart  muscle  has  fairly  grasped  its 
contents.  The  height  of  b  over  e  gives  some  indication  of 
the  difference  in  antero-posterior  diameter  of  the  heart  at 
commencing  systole  as  compared  with  the  end  of  the  sys- 
tole, for  it  need  scarcely  be  said  that  the  larger  the  quan- 
tity of  blood  contained  in  the  ventricle  at  the  commence- 
ment of  the  ventricular  systole,  the  greater  will  be  its 
antero-posterior  diameter,  and  therefore  the  more  powerful 
impulse  will  be  given  to  the  chest  wall  and  cardiograph 
button.  As  the  heart  empties  itself  during  systole  the  an- 
tero-posterior diameter  of  the  ventricles  diminishes  with 
corresponding  rapidity,  and  the  pressure  against  the  chest 
wall  and  cardiograph  button  falls  in  the  same  ratio.  The 
result  of  this  is  that,  ccEfej'is  paribus,  the  degree  to  which 
the  line  joining  b  and  e  descends  gives  a  valuable  indication 
regarding  the  quantity  of  blood  thrown  out  by  the  ventri- 
cles at  each  systole.  The  meaning  of  the  notches  c  and  d 
is  not  satisfactorily  understood.  This  much,  however,  is 
certain — viz.,  that  they  are  not  due  to  inertia  vibrations  of 
the  recording  lever,  as  has  been  asserted  by  some,  and. also 
that  in  not  a  few  cases  the  form  of  the  curve  lying  between 
the  lines  a  and  d  of  the  cardiogram  resembles  very  closely 
that  lying  between  the  lines  a  and  ^  of  our  normal  pulse 
curve  (Fig.  i.)  In  other  words  they  are  probably  due  to 
oscillations  of  the  column  of  blood  contained  in  the  ventri- 
cles and  larger  arteries.  The  notch  d,  when  well  marked, 
corresponds  to  the  conclusion  of  the  outflow  of  blood  from 
the  heart,  and  is  therefore  the  analogue  of  the  dicrotic  notch 
of  the  pulse  wave.  It  must  be  added,  however,  that  it  is 
by  no  means  uniformly  to  be  seen.  Of  greater  importance 
is  the  position  of  the  last  elevation  or  corner  of  the  curve 
at  e,  which  can  in  almost  all  curves  clearly  be  made  out. 
This  elevation  marks  the  commencing  relaxation  of  the  ven- 
tricular muscle,  and  by  measuring  the  distance  between  the 
lines  a  and  e  in  the  manner  which  will  be  described  in  a 
note  appended  to  this  chapter,  we  are  enabled  to  learn  with 
absolute  accuracy  the  duration  of  the  ventricular  systole 
in  any  given  case.  I  must  mention,  in  passing,  that  the 
duration  of  the  ventricular  systole,  and  the  duration  of  the 


114  MEDICAL  DIAGNOSIS. 

outflow  from  these  cavities,  by  no  means  necessarily  or  even 
usually  correspond.  The  ventricular  muscle  contracts  with 
a  certain  definite  force,  and  remains  contracted  for  a  cer- 
tain definite  time,  neither  of  these  being  influenced  by  the 
quantity  of  blood  contained  in  the  ventricle  at  the  com- 
mencement of  its  contraction.  The  result  of  this  is,  that 
where  a  very  small  quantity  of  blood  is  contained  in  the 
ventricles  at  the  commencement  of  their  contraction,  the 
outflow  from  them  may  have  concluded  some  tenths  of  a 
second  before  the  ventricles  begin  to  relax.  The  distance 
between  the  lines  e  and  /" gives  some  indication  of  the  rapid- 
ity with  which  the  heart  muscle  has  relaxed  after  the  con- 
clusion of  its  contraction.  Where  the  elasticity  of  the  heart 
muscle  is  modified,  as  when  the  blood  contains  a  largely 
diminished  quantity  of  oxygen,  the  ventricular  muscle  takes 
a  longer  time  to  relax  than  is  normally  the  case,  and  the 
curve  from  such  a  beat  descends  less  rapidly  than  in  health. 

The  cardiographic  curve  then  enables  us  to  measure  with 
very  considerable  accuracy  the  absolute  and  relative  dura- 
tion of  the  different  phases  of  the  cardiac  revolution.  It 
also  gives  us  some  idea  of  the  force  of  the  ventricular  con- 
traction corresponding  to  the  height  of  the  line  a  to  b,  and 
it  further  affords  valuable  information  regarding  changes 
in  the  force  and  frequency  of  the  heart's  action  which  make 
up  the  different  forms  of  irregularity  of  the  heart. 

It  is  unnecessary  to  refer  more  in  detail  to  the  normal 
typical  heart  curve,  and  I  turn  now  to  mention  those  dis- 
eased conditions  which  modify  its  form;  and  first,  with  re- 
gard to  the  cardiogram  in  aortic  regurgitation.  After  what 
has  been  said  regarding  the  meaning  of  the  various  parts 
of  the  normal  heart  curve,  it  is  not  difficult  to  understand 
in  what  way  these  may  be  modified  in  a  typical  case  of 
aortic  regurgitation.  In  the  first  place,  the  ventricle,  be- 
fore the  contraction  of  the  auricles,  is  abnormally  distended 
with  blood;  and  on  the  auricles  propelling  their  contents 
into  the  already  filled  ventricle,  an  abnormally  great  dis- 
tension of  the  ventricles  occurs.  The  result  of  this  is  that, 
in  cases  where  there  is  no  failure  in  the  power  of  the  auri- 
cular walls,  the  elevation  between  the  letters/" and  a  is  ab- 
normally high.  On  ventricular  contraction  occurring,  the 
antero-posterior  diameter  of  the  heart  diminishes  very 
rapidly,  corresponding  with  the  abnormally  large  quantity 
of  blood  contained  in  the  ventricle,  so  that  the  line  joining 
points  corresponding  to  a  and  e  is  unusually  steep,  while 


CIRCULATORY   SYSTEM.  II5 

the  regurgitation  of  blood  through  the  incompetent  aortic 
valves,  after  the  cessation  of  the  systole,  causes  a  dilatation 
of  the  relaxing  cardiac  muscle  sufficient  to  produce  in  most 
cases  a  very  well-marked  rise  after  e.  It  is  important  to 
note  that,  in  the  heart-curve  of  well  marked  aortic  regurgi- 
tation, it  is  often  impossible  to  find  the  exact  point  corre- 
sponding to  e  in  the  normal  curve  at  which  the  systole  sud- 
denly ceases.  The  corner  of  the  curve  preceding  the  de- 
scent is  usually  in  the  aortic  regurgitation  cardiogram  some 
fraction  of  a  second  later  that  the  time  of  commencing  re- 
laxation. In  all,  or  nearly  all,  cases  of  aortic  regurgitation, 
the  heart  curve  presents  two  well-marked  peaks,  and  this 
may  be  said  to  be  the  distinguishing  character  of  the  card- 
iogram of  that  disease,  and,  roughly  speaking,  the  more 
marked  this  bicornual  character  is,  the  greater  is  the  in- 
competence of  the  valve.  Such  is  the  curve  when  the  ven- 
tricular muscle  is  comparatively  unimpaired  in  contracting 
power,  as,  for  example,  in  sudden  rupture  of  one  of  the 
.cusps  of  the  valve,  or  when  one  of  these  is  artificially  de- 
stroyed in  the  lower  animals;  but  where  the  ventricle  no 
longer  completely  empties  its  contents  at  every  contraction, 
the  fall  of  the  line  from  ^^  to  somewhere  about  <?  becomes,  as  we 
might  anticipate,  less  and  less  steep,  due,  it  need  scarcely 
be  said,  to  the  slighter  diminution  in  the  antero-posterior 
diameter  of  the  ventricles,  which  occurs  when  the  ventricle 
no  longer  empties  itself  completely  at  each  contraction.  In 
these  cases  then,  the  bicornual  character  is  not  so  well 
marked  as  is  otherwise  the  case  in  that  disease,  but  still  it 
is  usually  sufficiently  recognizable. 

With  regard  to  the  curve  in  cases  of  mitral  incompetence, 
we  would  anticipate,  where  this  condition  was  well  marked, 
that  the  heart  curve  would  be  modified  chiefly,  if  not  ex- 
clusively, at  that  part  which  corresponds  in  time  to  the 
closure  of  the  auriculo-ventricular  valves;  in  other  words, 
at  the  point  marked  b  in  Fig.  5;  and  this  to  a  certain  ex- 
tent is  the  case.  As  a  rule,  we  find  the  ascending  line  from 
a  to  b  less  steep  than  is  normally  the  case,  and  the  peak  at 
b  rounded  off  to  some  extent  This  is  apparently  the  only 
characteristic  change  in  the  form  of  the  heart  curve  which 
results  from  simple  mitral  incompetence;  but  it  is  by  no 
means  usually  well  marked,  owing  to  the  fact  that  the 
large  quantity  of  blood  which  leaves  the  ventricle  during 
systole  causes  a  very  considerable  diminution  in  the  an- 
tero-posterior diameter  during  ventricular  systole;  so  that 


Tl6  MEDICAL  DIAGNOSIS. 

the  line  from  3  to  ^  is  unusually  steep,  thus  tending  to 
cover  the  rounding  off  which  the  peak  e  would  otherwise 
present.  It  is  rare  to  fine  that  the  reflux  of  blood  from  the 
auricle  into  the  ventricle  which  follows  the  conclusion  of 
the  systole  of  the  ventricle  distends  the  latter  with  sufficient 
force  to  cause,  as  is  the  case  in  aortic  regurgitation,  second 
elevation  after  e.  Finally,  where  the  auricles  are  hyper- 
trophied,  the  auricular  elevation  in  the  heart-curve  of  mitral 
incompetence  is  abnormally  well  marked.  Such  are  the 
changes  produced  by  simple  mitral  incompetence,  which 
has  been  more  or  less  completely  compensated  by  hyper- 
trophy of  the  auricle  and  dilation  and  hypertrophy  of  the 
ventricle;  but  in  cases  where  either  the  auricle  or  the  ven- 
tricle begins  to  fail,  there  are  endless  modifications,  which 
what  has  above  been  said  regarding  the  meaning  of  the 
different  parts  of  the  normal  heart  curve  will  enable  the 
physician  readily  to  understand;  but  it  should  be  added 
that  in  advanced  mitral  cases,  where  irregularity  is  a  pro- 
nounced element  of  the  case,  the  heart  curve  becomes  so. 
bizarre  in  form  that  it  is  difficult  and  sometimes  impossible 
to  understand  what  is  the  meaning  of  the  different  eleva- 
tions which  it  presents. 

With  regard  to  pure  mitral  stenosis,  we  would  a  priori 
expect  that  the  ascending  line  from  a  X.o  b  would  be  abnor- 
mally steep,  owing  to  the  abnormal  rigidity  of  the  mitral 
valve,  and  that  the  peak  b  would  be  unusually  sharp,  cor- 
responding as  this  does  with  the  thump  which  is  character- 
istic of  the  disease  in  question,  and  such  is  certainly  some- 
times the  case;  but  when  it  is  remembered  how  exceedingly 
rare  is  stenosis  of  the  mitral  valve  uncomplicated  with  regur- 
gigation,  it  need  cause  no  wonder  to  find  that  the  cardiogram 
in  mitral  stenosis  is  by  no  means  characteristic  or  typical. 
Still,  the  curve  in  all,  or  nearly  all,  cases  presents  suffi- 
ciently well-marked  deviations  from  the  normal  which  are 
fitted  to  throw  much  light  upon  the  condition  of  the  heart 
in  individual  instances;  and  careful  attention  to  the  period 
of  time  in  the  heart  revolution  at  which  these  abnormalities 
take  place  readily  indicates  their  meaning. 

There  are  many  modifications  of  the  heart  curve  which 
it  is  impossible  to  describe  here  in  detail;  and,  indeed,  in 
practice,  almost  every  imaginable  combination  of  the  ab- 
normalities above  described  is  encountered. 

Sphygmomanometer. — Very    recently,    Professor    S.  von 


CIRCULATORY    SYSTEM.  11/ 

Basch  has  introduced*  an  instrument,  to  which  he  gives  the 
above  name,  for  the  purpose  of  estimating  the  blood-pres- 
sure in  the  human  subject,  and  which  has  undoubtedly 
considerable  clinical  value.  In  principle  it  closely  resem- 
bles an  apparatus  previously  described  by  Prof.  C.  S.  Roy 
and  myself,t  which  was  more  specially  adapted  for  estimat- 
ing the  blood-pressure  in  the  lower  animals.  In  Von 
Basch's  sphygmometer,  a  small  cushion  of  membrane  is 
made  to  press  upon  the  skin  over  the  radial  artery,  and  the 
pressure  is  communicated  through  water  to  a  column  of 
mercury,  by  which  its  value  can  be  ascertained.  The  pres- 
sure of  the  cushion  upon  the  radial  artery  is  gradually  in- 
creased, until  all  pulsation  in  the  vessel  beyond  the  con- 
stricted point  ceases;  and  this  point  is  taken  as  the  maxi- 
mum arterial  pressure. 

While  open  to  many  sources  of  error,  the  readings  of  this 
instrument,  if  taken  with  sufficient  care,  appear  to  give  re- 
sults which  are  approximately  accurate;  at  any  rate,  quite 
sufficiently  so  for  ordinary  clinical  work.  In  healthy  men 
between  the  ages  of  twenty  and  sixty  the  pressure  averages 
about  150  mm.,  but  may  be  as  low  as  135  mm.,  or  as  high 
as  170  mm.  High  pressures  much  exceeding  these,  and 
running  as  high  as  245  mm.,  are  met  with  in  such  affections 
as  chronic  Bright's  disease  with  cardiac  hypertrophy,  while 
in  such  diseases  as  anaemia,  phthisis,  etc.,  the  blood-pres- 
sure is  found  to  be  very  low. 

This  instrument  seems  to  be  specially  suited  for  watch- 
ing the  progress  of  individual  cases  from  day  to  day,  and 
in  particular  for  observing  the  effects  of  treatment  upon  the 
blood-pressure. 

Note  on  the  Measurement  of  Tracings. 

In  order  to  measure  the  relative  duration  of  different 
parts  of  the  pulse  wave  (and  the  remarks  which  follow 
apply  equally  to  heart  curves),  a  certain  method  is  neces- 
sary to  correct  the  error,  due  to  the  fact  that  the  point  of 
the  lever  describes,  not  a  straight  vertical  line,  but  the  seg- 
ment of  a  circle.  The  most  convenient  method  of  doing 
this  is  as  follows  :  Having  obtained  a  satisfactory  curve 

*Zeitschrift  f.  kl.  med.,  vol.  ii.,  1881,  p.  79;  and  vol.  iii.  p.  502, 
f  Verha7idlu7ig  der physiol.    Gesdlschaft  zu  Berlin,  15th  Feb.,  1878.  Jour- 
nal of  Pysiology,  vol.  ii.  p. 323* 


Il8  MEDICAL  DIAGNOSIS. 

from  the  radial  artery,  the  sphygmograph  is  removed  from 
the  arm,  and  the  paper  in  its  holder  is  again  passed 
through  the  clockwork,  the  point  of  the  lever  being  fixed 
so  as  to  draw  a  straight  abscissa — /.  e.,  one  parallel  to  the 
line  of  movement  of  the  paper.  This  line  may  be  drawn 
either  below  the  curve  or  through  it;  but  where  absolute 
accuracy  is  desired,  it  ought  to  be  at  the  level  of  the  centre 
of  that  circle  of  which  the  lever  describes  a  segment  when 
the  paper  is  at  rest.  The  paper  is  then  either  drawn  back- 
wards or  put  a  third  time  through  the  clockwork,  and  suc- 
cessive parallel  curved  lines  are  described  by  the  lever  point 
connecting  those  portions  of  the  curve  which  it  is  desired 
to  measure  with  the  abscissa  line.  In  Fig.  i  there  are  cer- 
tain dotted  lines,  of  which  the  horizontal  represents  the 
abscissa  line,  and  the  vertical  curved  lines  represent  seg- 
ments of  the  circle  described  by  the  recording  lever.  Since 
the  movement  of  the  clockwork  of  the  sphygmograph  is, 
during  the  time  when  any  single  pulse  curve  is  being  re- 
corded, fairly  uniform,  and  since  the  rapidity  of  the  heart 
beat  is  readily  learned  by  the  watch,  it  is  not  difficult  to  say 
what  fraction  of  a  second  corresponds  to  the  distance  be- 
tween any  two  of  our  vertical  curved  lines.  For  example, 
in  Fig.  I  the  pulse  was,  let  us  say,  sixty  i-n  the  minute;  and 
as  the  distance  from  the  vertical  lines'^  to  c  is  roughly  one- 
third  of  the  whole,  we  know  that  the  duration  of  that  por- 
tion of  the  pulse  wave  is  equal  to  one-third  of  a  second. 
In  the  same  way,  the  duration  of  any  other  portion  of  the 
pulse  wave  may  be  determined  with  sufficient  accuracy. 
This  method  enables  us  to  learn  the  duration  of  any  of 
the  phases  of  the  pulse  curve,  while  the  relative  import- 
ance of  the  various  parts  of  the  same  curve — that  is, 
the  tension  of  the  blood  in  the  artery  at  different  points — 
is  represented  by  the  height  of  the  tracing  as  measured  from 
a  horizontal  line  running  through  the  lowest  part  of  the 
pulse  wave. 


RESPIRATORY   SYSTEM.  II9 


CHAPTER  XIII. 

Respiratory  System. 

The  first  symptoms  which  require  notice  in  connection 
with  the  respiratory  system  are: 

Subjective  Phenomena,  such  as  pain,  tickling,  burning,  etc., 
which  are  frequently  felt  over  the  larynx,  trachea,  and 
bronchi,  when  these  structures  are  the  seat  of  disease,  and 
are  usually  aggravated  by  pressure,  and  by  the  acts  of 
speaking  and  coughing.  Faiii  may  manifest  itself  in  con- 
nection with  disease  of  the  lung  tissue,  but  it  attains  its 
greatest  importance  in  cases  of  pleurisy,  where  the  pain  has 
a  peculiar  dragging,  shooting  character,  is  increased  by 
pressure,  and  by  any  movement  of  the  thorax.  Its  differen- 
tial diagnosis  is  very  important. 

Distinguish  the  pain  of  pleurisy: 

(i.)  From  the  paift  of  pleurodynia,  or  rheumatism  of  the  in- 
tercostal muscles.  In  this  condition  the  pain  comes  on 
with  excessive  suddenness,  after  some  abrupt  movement, 
and  is  unaccompanied  by  pyrexia  or  by  friction  sound.* 

(2.)  Fro77i  the  pain  of  intercostal  neuralgia. — In  this  affection 
there  are  commonly  three  tender  points  in  the  course  of  the 
affected  nerve,  one  close  to  the  vertebral  column,  one  in 
the  axilla,  and  a  third  over  the  terminal  branches  near  the 
sternal  border.  The  presence  of  these  points,  the  neuralgic 
character  of  the  pain,  and  the  absence  of  all  pulmonary 
physical  signs,  except  such  alteration  of  the  respiration  as 
the  pain  occasions,  will  suffice  to  distinguish  this  affection 
from  pleurisy. 

(3.)  From  the  pain  of  Herpes  Zoster. — This  eruption,  which 
follows  the  course  of  the  intercostal  nerves,  is  sometimes 
preceded  by  severe  pain,  usually  of  a  burning  character. 
The  marked  cutaneous  hypersesthesia  which  frequently  ac- 
companies this  pain  will  suffice  to  distinguish  it  from  pleu- 

*  It  must  be  remembered,  however,  that  this  auscultatory  phenomenon 
may  be  awanting  in  the  early  stage  of  pleurisy,  so  that  the  physician 
may  have  to  refrain  from  a  positive  diagnosis  until  this  symptom  has  had 
time  to  develop. 


120  MEDICAL  DIAGNOSIS. 

risy.  The  eruption  is  often  followed  by  long  persisting 
neuralgia,  the  nature  of  which,  however,  will  be  at  once 
made  clear  by  the  history  of  preceding  herpetic  eruption. 

(4.)  From  the  Pain  of  Periostitis  and  other  Surgical  Affections 
of  the  Thoracic  Wall. — Careful  examination  of  the  ribs  will 
make  clear  the  nature  of  such  pain. 

Breathing  will  be  more  conveniently  considered  hereafter. 

Cough. — The  removal  of  foreign  substances  from  the 
respiratory  passages  is  effected  by  means  of  the  acts  of 
sneezing  and  coughing — two  forms  of  explosive  expiration 
which  are  both,  as  a  rule,  excited  reflexly,  and  which  both 
consist  in  a  closure  of  the  respiratory  passages  after  a  deep 
inspiration,  followed  by  a  sudden,  forcible,  and  noisy  open- 
ing of  the  same,  the  result  of  a  powerful  expiratory  effort. 
In  the  case  of  sneezing,  the  closure  is  effected  by  the 
pressure  of  the  soft  palate  by  means  of  the  tongue,  on  the 
posterior  wall  of  the  pharynx,  while  in  coughing  the  closure 
takes  place  at  the  glottis.  Of  these  two  acts  that  of  cough- 
ing is  by  far  the  most  important.  Sneezing  need  not  be 
further  considered  here. 

Coughing  is  excited  by  iritation  of  the  terminal  branches 
of  the  superior  laryngeal  nerve  distributed  to  the  mucous 
membrane  of  the  larynx  and  trachea.  The  inhalation  of 
cold  air,  or  of  air  laden  with  dust,  the  passage  into  the 
larynx  of  particles  of  food,  or  other  foreign  bodies,  and  the 
collection  of  secretions,  or  of  such  morbid  products  as  blood 
or  pus,  all  tend  to  excite  coughing,  which  is  more  liable  to 
occur  when  in  addition  there  is  hyperaesthesia  of  the  parts, 
the  result  of  catarrh  or  inflammation.  The  terminal 
branches  of  the  vagus  distributed  to  the  bronchi,  lung 
tissue,  pleura,  or  abdominal  viscera  may  be  the  starting 
point  of  the  irritation,  while  in  sensitive  individuals,  the 
action  on  the  skin  of  a  draught  of  cold  air  is  sufficient  to  set 
up  cough.  Anaesthetic  conditions  of  the  larynx  are  occa- 
sionally met  with  in  which  such  local  irritations  as  those 
mentioned  are  not  sufficient  to  excite  cough;  and  depres- 
sion of  the  activity  of  the  reflex  centre  in  the  medulla,  the 
result,  for  example,  of  the  accumulation  of  carbonic  acid 
in  the  blood,  or  of  the  action  of  opium,  may  diminish  or 
completely  abolish  the  act  of  coughing,  and  thereby  cause 
a  dangerous  accumulation  of  secretion  in  the  air-cells. 

In  examining  cough  as  a  symptom,  it  is  well  to  note: 


RESPIRATORY    SYSTEM.  T2I 

isf.  Its  Frequency  and  Rhythfn. — Whether  it  comes  fre- 
quently, eacli  individual  cough  being  separated  by  a  toler- 
ably constant  interval,  or  whether  there  occur  paroxysms 
of  coughing  with  intervals  of  quietness. 

2nd.  Its  Character. — This  may  vary  very  greatly.  The 
cough  may  be  dry,  as  in  pleurisy,  the  first  stage  of  phthisis, 
etc.,  or  moist,  as  in  chronic  bronchitis,  and  in  the  last  stages 
of  phthisis.  It  may  be  painful,  as  in  acute  pleurisy,  and  it 
is  important  to  observe  that  the  patient  then  instinctively 
tries  to  suppress  the  cough  which  gives  him  so  much  pain; 
and  this  short,  dry,  suppressed  cough  is  frequent  at  the 
commencement  of  acute  pneumonia,  and  also  in  cases  of 
intercostal  neuralgia,  pleurodynia,  pericarditis,  and  perito- 
nitis. Very  different  from  this  is  the  loud  barking  cough 
of  hysteria,  which  is  obviously  produced  at  will,  and  cal- 
culated to  attract  the  the  utmost  amount  of  attention.  It  is 
important  to  recognize  the  variety  of  cough  met  with  in 
affections  of  the  larynx.  In  laryngitis,  even  w^hen  the  dis- 
ease is  very  slight,  the  cough  is  hoarse,  husky,  stridulous, 
and  croupy  in  character;  and  when  much  submucous  infil- 
tration has  taken  place,  or  if  there  be  extensive  formation 
of  false  membrane,  the  act  of  coughing  is  almost  noiseless. 
The  hard,  metallic  lar3^ngeal  cough  met  with  in  cases  of 
aortic  aneurism,  when  the  recurrent  laryngeal  nerve  is 
interfered  with,  is  often  of  considerable  diagnostic  value. 

2,rd,  Notice  w^hether  the  cough  is  obviously  brought  on 
by  such  causes  as  exertion,  change  of  posture,  inhalation  of 
cold  air,  of  dust,  or  of  irritating  chemical  vapors. 

Acth.  Notice  if  the  paroxysm  terminates  in  a  fit  of  vomit- 
ing, as  often  occurs  in  whooping-cough,  phthisis,  and 
chronic  bronchitis,  or  in  the  prolonged,  clear,  shrill  inspira- 
tion which  characterizes  the  first  of  these  affections. 

Sputa. — A  very  important  aid  to  diagnosis  is  found  in  the 
examination  of  the  sputa,  particularly  at  the  commencement 
of  morbid  processes  in  the  chest,  when  physical  signs  are  not 
yet  marked.  In  almost  every  affection  of  the  respiratory 
organs,  more  or  less  expectoration  follows  the  act  of  cough- 
ing. Occasionally,  however,  this  is  absent;  and  in  the  case 
of  young  children,  even  when  the  cough  is  accompanied  with 
expectoration,  the  sputum  is  swallowed  so  soon  as  it  reaches 
the  mouth.  It  must  also  be  borne  in  mind  that  the  material 
coughed  up  does  not  always  come  originally  from  the  res- 
piratory tract;  for  secretions  from  the  mouth,   nose,  a,n4 


122  MEDICAL  DIAGNOSIS. 

pharynx  may  pass  the  rimaglottidis,  and,  irritating  the  mu- 
cous membrane  of  the  larynx,  be  coughed  up  again.  Bleed- 
ing from  the  posterior  nares  may  thus  simulate  haemop- 
tysis. 

Chemical  Characters. — As  yet  the  chemical  analysis  of  sputa 
has  not  proved  of  much  diagnostic  value.  Consisting,  in 
the  main,  of  water,  sputa  have  at  different  times  been  found 
to  contain  serum  albumen,  paraglobulin,  paralbumen,  my- 
osin, nuclein,  glycogen,  various  fatty  acids,  leucin,  tyrosin, 
etc.,  in  addition  to  the  mucin  which  is  invariably  met  with 
even  in  the  healthy  state,  and  which  imparts  to  the  expec- 
toration its  peculiar  viscid  and  glassy  appearance.  Albu- 
men is  always  present  when  there  is  inflammation  of  the 
air-passages  or  lung-substance.  In  cases  of  diabetes,  sugar 
has  been  detected  in  the  expectoration,  and  in  renal  affec- 
tions urea  may  sometimes  be  found. 

Macroscopic  Characters  of  Sputa* 

For  purposes  of  ready  description  the  various  varieties  of 
sputa  may  be  classified  as  follows,  each  being  named  after 
its  principal  constituent. 

(i.)  Mucous  sputuin  is  transparent,  clear  and  glassy,  and 
has  a  viscid  and  ropy  consistence  which  is  best  appreciated 
by  pouring  it  from  one  vessel  into  another.  It  is  sometimes 
present  in  health,  often  becoming  constant  in  advanced  life, 
but  is  most  frequently  found  in  the  earlier  stages  of  bron- 
chial catarrh.  There  is  a  very  slight  admixture  of  mucous 
and  pus  corpuscles, 

(2.)  Muco-pu7'ulent  sputum  occurs  in  almost  every  affection 
of  the  bronchi  and  lung.  When  allowed  to  stand  in  a  ves- 
sel, the  pus  corpuscles  sink  to  the  bottom,  leaving  the  clear 
mucus  floating  on  the  surface.  Sometimes,  however,  a  more 
intimate  mixture  of  these  two  elements  takes  place. 

(3.)  Purulent  sputu7n  possesses  all  the  characters  of  ordi- 
nary pus  as  obtained  from  an  abscess.  It  has  the  same  yel- 
low opaque  appearance,  and  separates  in  the  same  way  into 
two  layers  when  allowed  to  stand,  the  lower  being  composed 
of  pus  corpuscles,  the  upper  of  plasma.  This  variety  of 
sputum  is  usually  derived  from  suppurating  cavities  in  the 

*In  all  cases  of  laryngeal  and  pulmonary  disease  the  sputa  should  be 
regularly  examined,  and  for  this  purpose  the  expectoration  for  twenty- 
four  hours  should  be  collected  in  a  glass  vessel  of  such  shape  as  to  permit 
pf  rapid  and  satisfactory  inspection. 


RESPIRATORY    SYSTEM.  I23 

lung  tissue,  or  is  the  result  of  other  collections  of  pus  (as, 
for  example,  empyaema)  bursting  into  a  bronchus. 

(4.)  Serous  Sputum  is  that  form  which  is  met  with  when 
copious  transudation  takes  place  from  the  pulmonary  cir- 
culation, as  in  oedema  of  the  lungs.  It  has  a  characteristic 
thin,  transparent  appearance,  and  is  usually  copious  and 
frothy. 

(5.)  Sanguineous  Sputum. — The  sputum  may  be  simply 
streaked  with  blood  (as  in  the  early  stages  of  phthisis,  etc.), 
or  the  blood  may  be  mixed  intimately  through  the  mass. 
This  latter  form  is  that  most  usually  met  with  in  the  later 
stages  of  phthisis,  in  cases  of  hemorrhagic  infarction,  and 
in  lobar  pneumonia.  In  the  last-named  affection  the  sputum 
is  of  a  rusty  color,  due  to  some  chemical  alteration  of  the 
blood  pigment,  and  this  may  pass  into  citron-yellow 
and  green.  It  has  been  already  said  that  blood  from  the 
throat  or  posterior  nares  may  trickle  into  the  trachea  and 
be  coughed  up.  The  primary  source  of  the  hemorrhage  is 
then,  however,  usually  clear.  More  difficult  is  it  to  distin- 
guish hemorrhage  from  the  lungs  (haemoptysis)  from  that 
from  the  stomach  (haematemesis).  The  history  and  physi- 
cal examination,  and  the  nature  of  the  act  by  which  the  blood 
reaches  the  mouth,  will  help  greatly  towards  diagnosis;  but 
it  must  be  remembered  that  the  blood  coughed  up  may  be 
swallowed  and  then  vomited.  In  haemoptysis  the  blood  is 
usually  bright  red,  fluid,  and  frothy,  has  an  alkaline  reaction, 
and  when  examined  microscopically  is  found  to  contain 
more  or  less  of  those  cellular  elements  which  are  peculiar 
to  the  respiratory  tract.  On  the  other  hand,  in  haemate- 
mesis the  blood  is  dark  and  venous-,  sometimes  chocolate- 
brown,  resembling  coffee-grounds,  often  clotted,  free  from 
froth,  acid  in  reaction,  and  when  microscopically  examined 
is  found  to  contain  fragments  of  food. 

Physical  Characters  of  the  Sputa. 

(i.)  Quantity.— Tho.  amount  of  expectoration  may  vary  very 
much,  and  this  indication  may  become  of  considerable  di- 
agnostic value,  as,  for  example,  when  in  the  course  of  some 
acute  affection  (bronchitis,  pneumonia)  the  scanty  sputum 
suddenly  becomes  more  abundant  and  more  readily  expec- 
torated, showing  thereby  that  the  acuteness  of  the  inflam- 
mation is  subsiding.  In  bronchiectasis  very  large  quanti- 
ties of  sputum  are  brought  up  at  one  time,  and  so  marked 


124  MEDICAL  DIAGNOSIS. 

is  this  symptom  that  it  may  suffice  in  many  cases  to  estab- 
lish a  diagnosis  in  the  absence  of  other  signs. 

(2.)  Form  and  Consistefice. — The  more  mucus  the  sputum 
contains,  the  firmer  will  be  its  consistence,  and  the  more 
distinct  its  form.  Tenacious  sputa  are  consequently  found 
in  the  acute  stage  of  bronchitis,  pneumonia,  phthisis,  etc. 
In  the  absence  of  mucus,  the  sputa  lose  their  individual 
shapes,  and,  when  collected  in  a  vessel,  they  coalesce  with 
each  other.  Such  is  the  case  with  the  purely  purulent  and 
the  serous  sputa.  Tough  sputa  from  phthisical  cavities 
preserve  their  flattened,  coin-like  (nummular)  shape  after 
expectoration — an  indication  of  some  diagnostic  value. 

(3.)  S?nell. — As  a  rule,  sputa  are  devoid  of  any  very  marked 
odor.  When,  however,  putrefaction  becomes  developed, 
the  odor  of  the  breath  and  of  the  expectoration  becomes 
most  overpowering.  This  occurs  to  a  marked  degree  in 
bronchiectasis,  putrid  bronchitis,  and  pulmonary  gangrene. 

(4.)  Color. — To  the  yellow  or  yellow-green  tinge  which 
is  imparted  to  the  sputum  by  pus  cells  when  they  are  pres- 
ent, allusion  has  already  been  made.  The  red  color  of 
sanguineous  sputa  has  also  been  described,  passing  into 
rust-color,  yellow,  saffron,  and  finally  green,  as  the  haemo- 
globin becomes  more  and  more  highly  oxidized.  Lower  has 
pointed  out  that  in  very  hot  weather  a  similar  yellow  tint  is 
sometimes  to  be  seen  in  the  sputum,  resulting  from  the  de- 
velopment of  a  fungus  (leptothrix).  A  yellow  or  a  green 
discoloration  frequently  appears  in  the  sputa  in  cases  of 
jaundice,  due  to  the  presence  of  bile  pigment;  and  those 
who  are  much  exposed  to  smoke,  or  who  work  in  coal-mines, 
frequently  expectorate  the  black  carbonaceous  particles, 
which  they  have  inhaled,  to  such  an  extent  as  to  blacken  the 
whole  of  the  sputum. 

Microscopic  Examination  of  the  Sputa, 

(i.)  Pus,  Blood,  and  Mucus  Corpuscles. — The  recognition  of 
these  corpuscles  is  very  readily  made  by  means  of  the  mi- 
croscope. What  diagnostic  significance  attaches  to  each 
has  been  already  stated,  and  does  not  demand  further  re- 
mark. 

(2.)  Epithelial  Cells.^ — The  ordinary  pavement  epithelial 

*  These  structures  are  best  seen  when  stained  with  methyl-anilin.  A 
small  particle  of  the  sputum  should  be  mixed  on  the  slide,  with  a  drop  of 
a  watery  solution  (i-iooo)  of  that  pigment. 


RESPIRATORY   SYSTEM.  1 25 

cells  of  the  mouth  are  almost  invariably  present  in  sputa, 
becoming  mixed  with  the  expectoration  on  its  passage 
through  the  mouth.  They  are  of  large  size,  polygonal  in 
shape,  finely  granular,  and  possess  a  large,  refractive,  ovoid 
nucleus. 

The  columnar  epithelium  of  the  bronchial  mucous  mem- 
brane almost  never  appears  in  the  sputa.  When  ciliated 
cells  are  present,  they  usually  come  from  the  nasal  cavity. 

Much  more  important  for  diagnosis  is  the  occurrence  of 
the  epithelium  of  the  pulmonary  alveoli.  As  Friedlander* 
has  shown,  these  alveolar  epithelium  cells  never  appear  in 
the  sputum  in  their  normal  flattened  condition,  but  invari- 
ably swell  up  and  become  spherical  when  brought  in  con- 
tact with  liquid,  or  when  they  undergo  inflammatory 
change.  In  the  sputa,  this  alveolar  epithelium  is  readily 
recognized.  The  cells  are  spherical  or  slightly  oval,  have 
a  diameter  two  to  four  times  greater  than  that  of  a  leucocyte 
(thus  distinguished  from  all  other  round  cells  in  the 
sputum),  contain  granular  protoplasmic  masses,  and  pos- 
sess one  or  more  large  oval  nuclei  with  distinct  nucleoli. 
They  further  differ  from  all  other  cells  to  be  found  in  the 
sputum  in  that  they  readily  become  pigmented,  and  under- 
go fatty  and  myelin  \  degeneration — changes  which  the 
other  varieties  seldom  or  never  show.  Bearing  these  points 
in  view,  the  distinguishing  of  the  alveolar  epithelium  can 
seldom  be  a  matter  of  difficulty. 

Regarding  the  diagnostic  value  of  these  cells,  X  it  is  im- 
portant to  observe  that  above  the  age  of  thirty  to  thirty- 
five  years  alveolar  epithelium  is  to  be  found  in  the  sputa  of 
perfectly  healthy  persons,  but  that  variety  of  cell  is  not 
found  in  individuals  whose  age  is  below  thirty.  At  all  ages, 
however,  alveolar  epithelium  may  be  found  in  the  sputa  of 
many  affections  of  the  respiratory  organs — in  oedema, 
hypostatic  congestion,  hemorrhagic  infarction,  pneumonia, 
and  in  all  the  forms  of  phthisis.  In  simple  bronchial 
catarrh  of  individuals  under  thirty,  no  alveolar  epithelium 


*  Ueber  Lungenentziindung  nebst  Bemerkungen  iiber  das  normale  Lungen- 
epithet.     Berlin,  1873. 

f  Panizza  {Deut.  Arch.,  vol.  xxviii.,  1881,  p.  343)  argues  strongly  in 
favor  of  the  view  that  this  myelin  transformation  is  mucous  degenera- 
tion. 

X  On  this  subject  see  the  very  careful  paper  by  Guttman  and  Smidt  in 
the  Zeitschr.  f.  klin.  med.,  iii.,  1881. 


126  MEDICAL  DIAGNOSIS. 

is  to  be  found  in  the  sputa,  unless  the  very  finest  bron- 
chioles be  affected,  and  then  these  cells  appear  only  in  small 
number.  In  commencing  phthisical  catarrh  of  the  apex, 
however,  alveolar  epithelium  is  to  be  found  in  considerable 
quantity  long  before  any  physical  sign  can  be  detected,  and 
in  young  individuals  in  whom  all  the  other  causes  men- 
tioned may  be  excluded,  the  occurrence  of  alveolar  epithe- 
lium is  almost  certainly  diagnostic  of  commencing  phthisis. 

(3.)  Debris  of  Limg  Tissue. — In  any  disease  which  involves 
destruction  of  lung  tissue  we  may  find  in  the  sputum  the 
elastic  fibres  which  had  formed  the  framework  of  the 
broken  down  alveolar  walls.  These  fibres  may  be  distin- 
guished under  the  microscope  without  difficulty.  They 
usually  lie  in  groups  coiled  and  twisted,  sometimes  recall- 
ing by  their  arrangement  the  outline  of  the  alveoli.  Their 
dichotomous  branching  and  well-defined  double  contour, 
and  still  more,  their  resistance  to  the  action  of  caustic 
alkalies,  make  their  recognition  a  matter  of  little  difficulty. 
It  is  well,  as  Fenwick  recommends,  to  boil  the  sputa  with 
caustic  soda  until  the  mixture  becomes  thin  and  watery. 
The  elastic  fibres  will  then  readily  sink  to  the  bottom  of  a 
conical  glass,  and  can  be  secured  by  means  of  a  pipette. 

While  the  debris  of  lung  tissue  occurs  by  far  most  fre- 
quently in  the  sputum  of  phthisis,  it  may  also  be  found  in 
cases  of  pulmonary  abscess  and  of  gangrene  of  the  lung. 
In  the  last-named  affection  the  lung  tissue  is  only  to  be 
found  in  very  fresh  sputum.  It  rapidly  disappears,  being 
apparently  acted  upon  and  dissolved  by  some  peculiar  fer- 
ment which  is  present  in  the  expectoration  in  such  cases. 
It  need  hardly  be  said  that  where  such  elastic  fibres  occur, 
we  have  absolute  proof  of  the  destruction  of  lung  tissue, 
hence  the  extreme  importance  of  this  symptom  in  case  of 
phthisis  where  the  physical  signs  are  not  distinct. 

(4.)  Fibrinous  Bronchial  Casts. — In  pneumonia  and  in 
croupous  bronchitis,  there  are  to  be  found  in  the  expec- 
toration casts  in  fibrine  of  the  finer  bronchioles  and  their 
branches.  In  the  sputum  they  are  usually  rolled  together, 
and  only  unroll  and  spread  out  when  washed  with  water. 
The  perfect  way  in  which  they  reproduce  the  arrangement  of 
the  bronchioles  makes  the  recognitiorn  of  these  casts  easy. 
In  pneumonia  they  are  most  numerous  in  the  sputum  on 
the  third  and  fourth  day  of  the  affection,  and  Remak,  who 
devoted  much  attention  to  the  subject,  pointed  out  that  the 
earlier  these  casts  appeared,  and  the  greater  their  quantity, 


RESPIRATORY   SYSTEM.  127 

the  more  quickly  would  recovery  set  in  and  the  more  com- 
pletely would  the  affected  lung  recover  from  the  disease. 

(5.)  Crystals  are  occasionally  met  with  in  sputa,  the  most 
common  being  the  long,  fine,  colorless,  needle-shaped 
crystals  of  the  fatty  acids.  They  have  some  superficial 
resemblance  to  elastic  fibres,  but  are  easily  distinguished 
by  the  fact  that  they  dissolve  at  once  in  ether,  a  reagent 
which  does  not  affect  elastic  fibre.  These  fatty  acids  are 
found  in  cases  of  putrid  bronchitis,  bronchiectasis,  and  pul- 
monary gangrene. 

Another  variety  of  crystal  which  may  be  found  in  the 
sputum  are  those  usually  known  as  Charcot's  crystals,  after 
the  name  of  their  discoverer.  Their  exact  nature  is  a 
matter  of  some  doubt.  In  shape  they  vary  somewhat,  but 
are  usually  long,  fine,  sharp,  and  spindle-shaped;  they  are 
colorless,  are  insoluble  in  alcohol,  but  are  readily  dissolved 
by  acids  or  alkalies.  Charcot's  crystals  occur  most  fre- 
quently in  asthma,  and  have  been  supposed  to  be  the  ex- 
citing cause  of  the  paroxysm,  by  irritating  the  terminations 
of  the  vagus. 

Other  crystals,  such  as  cholesterin,  haematoidin,  leucin, 
tyrosin,  oxalic  acid,  and  triple  phosphate,  occur  in  the 
sputum,  but  do  not  demand  special  notice  here. 

(6.)  Micro-organisms  of  various  kinds  may  be  found  in  the 
sputum,  such  as  leptothrix,  oidiuin  albicans^  and,  rarely,  sar- 
cina.  Bacteria  and  vibriones  are  very  frequently  to  be  seen 
in  the  sputum  of  gangrene  and  bronchiectasis. 

By  far  the  most  important  of  these  micro-organisms, 
however,  is  the  tubercle -bacillus,  which  Koch  has  very  re- 
cently *  discovered.  They  are  delicate,  rod-shaped  struc- 
tures, in  length  usually  about  one-fourth  or  one-third  the 
diameter  of  a  blood  corpuscle,  and  are  motionless.  They 
can  only  be  detected  after  careful  staining,  and  for  this 
purpose  the  method  of  Ehrlich  appears  to  be  the  most 
satisfactory.  The  procedure  is  as  follows:  A  thin  layer  of 
sputum  is  spread  on  a  cover-glass,  which  is  then  gently 
heated  over  a  flame  for  a  few  seconds  to  coagulate  the 
albumen,  and  placed  in  a  staining  solution  prepared  as 
follows:  Five  cubic  centimetres  of  pure  anilin  are  added  to 
100  cubic  centimetres  of  distilled  water,  well  shaken  and 
filtered,  and  to  the  filtrate  a  saturated  alcoholic  solution  of 
fuchsin  or  methyl-violet  is  added  until  precipitation  com- 

*  Berl.  kl.    Woch.,  loth  April,  1882. 


128  MEDICAL   DIAGNOSIS. 

mences.  The  cover-glass  is  allowed  to  float  on  this  for  half 
an  hoar.  It  is  then  washed  in  a  solution  of  nitric-acid  (i 
to  2),  and  afterwards  in  distilled  water.  In  this  way  the 
stain  is  extracted  from  everything  but  the  bacilli.  The  de- 
tection of  these  tubercule-bacilli  in  the  sputum  suffices  to 
establish  a  diagnosis  of  tuberculous  affection  of  the  lung. 

Echinococcus-vesicles  are  in  rare  cases  to  be  found  in 
the  expectoration,  having  either  been  previously  encysted 
in  the  lung,  or  having  bored  their  way  from  the  liver  into  a 
bronchus. 

(7.)  Foreign  Bodies. — To  the  presence  of  carbonaceous 
particles  in  the  sputum  allusion  has  already  been  made. 
Fragments  of  food,  when  accidentally  present,  are  easily 
recognized  by  means  of  the  microscope. 


CHAPTER  XIV. 

Respiratory  System — {contiuued). 

EXAMINATION    OF    NARES    AND    LARYNX. 

We  now  proceed  to  the  physical  examination  of  the  or- 
gans of  respiration,  and  these  will  be  considered  in  the 
order  in  which  they  naturally  come — the  Nares,  the 
Pharynx,  the  Larynx  and  Trachea,  and  the  Lungs. 

Nares. 

The  examination  of  the  nostrils  appertains  more  to  the 
domain  of  surgery  than  to  that  of  medicine;  but  it  must  be 
briefly  alluded  to  here.  Obstruction  of  the  nasal  passages 
obliges  the  patient  to  breathe  through  the  mouth;  and  the 
effect  of  this  upon  the  moisture  of  the  tongue  and  lips  has 
been  already  commented  upon  in  Chap.  I.  The  resonance 
of  the  nasal  cavities  is  of  great  importance  in  connection 
with  the  voice;  and  when  this  resonance  is  interfered  with 
by  obstruction  of  the  nares,  the  voice  acquires  a  peculiar 
and  characteristic  nasal  sound.  The  nares  may  be  examined 
by- 

(i.)  Palpation. — The  finger  may  to  a  certain  extent  be 
made  to  explore  both  anterior  and  posterior  nares,  and  the 


RESPIRATORY   SYSTEM.  1 29 

presence  of  polypi  and  other  tumors   may  thus  be  ascer- 
tained. 

(2.)  Inspection. — The  anterior  nares  maybe  inspected  with 
the  aid  of  a  nasal  speculum.  With  such  an  instrument  it  is 
often  possible  to  examine  the  mucous  membrane  of  the 
nostrils  and  the  posterior  wall  of  the  pharynx,  and  even 
the  orifices  of  the  Eustachian  tubes.  The  more  posterior 
nasal  structures  are.  however,  best  brought  into  view  by 
means  of  rhinoscopy.  This  method  of  examination  closely 
resembles  laryngoscopy  (to  be  presently  described),  the 
mirror  is,  however,  turned  in  the  reverse  direction.  It  is 
passed  over  the  back  of  the  tongue  until  it  touches  the  pos- 
terior wall  of  the  pharynx,  where  it  is  held  with  the  surface 
directed  upwards  and  forwards.  If  the  uvula  hang  loosely 
downwards  it  presents  no  impediment;  but  should  it  con- 
tract, turn  backwards,  and  close  up  the  posterior  nares,  it 
must  be  drawn  forwards  with  a  hook.  Having  in  this  way 
obtained  a  view  of  the  posterior  nares  of  the  upper,  middle, 
and  lower  passages,  and  of  the  openings  of  the  Eustachian 
tubes,  we  must  note  the  color  of  the  mucous  membrane 
covering  these  parts,  and  the  presence  or  absence  of  swell- 
ing, ulceration,  new  formations,  foreign  bodies,  etc. 

Pharynx. 

The  pharyngeal  passage,  forming  part  of  the  alimentary 
tract  as  well  as  of  the  respiratory,  has  been  already  de- 
scribed in  sufficient  detail,  and  need  not  again  detain  us  at 
this  point. 

Larynx. 

Voice. — As  an  index  of  the  state  of  the  larynx,  the  voice 
is  of  the  utmost  importance.  All  affections  of  the  vocal 
cords,  whether  ulceration,  swelling,  or  new  formation,  and 
all  acute  and  subacute  inflammations  of  the  larynx,  are 
followed  by  huskiness  of  the  voice.  When  therefore,  the 
voice  is  clear  and  good,  all  such  affections  may  be  excluded. 
Aphonia  {a,  priv.,  qiGovy,  sound),  or  loss  of  voice,  may,  how- 
ever, result  from  other  causes,  such  as  paralysis  of  the  mus- 
cles of  the  larynx,  which  may  be  due  to  central  or  peri- 
pheral nerve  affection,  or  simply  to  the  exhaustion  of  severe 
disease;  or  it  may  be  of  a  purely  functional  nature  as  met 
with  in  hysteria.  A  degree  of  aphonia  may  occur  along 
with  considerable  dyspnoea  owing  to  the  embarrassment  of 


I30  MEDICAL  DIAGNOSIS. 

breathing;  and  where  from  central  nervous  disease  the  re- 
spiratory muscles  are  paralyzed,  the  voice  fails. 

Aphonia,  must,  of  course,  be  distinguished  from  aphasia 
(loss  of  speech),  in  which  the  power  of  phonation  is  not 
affected,  and  also  from  deaf-mutism. 

Laryngeal  Palpation. — External  palpation  of  the  larynx 
may  occasionally  detect  tender  points,  the  result  of  inflam- 
matory changes,  which  may  be  more  clearly,  localized  by 
laryngoscopic  examination.  By  placing  a  finger  on  either 
side  of  the  larynx  whilst  the  patient  speaks,  the  transmitted 
vibration  of  the  vocal  cords  can  be  clearly  felt.  Normally 
this  is  equal  on  both  sides,  but  should  one  cord  be  para- 
lyzed, the  vibration  will  fail  on  the  corresponding  side,  and 
in  this  way  a  rapid  and  accurate  diagnosis  can  sometimes 
be  made. 

Internal  palpation  of  the  larynx — that  is,  the  examina- 
tion of  the  rima  glottidis  and  neighboring  parts  with  the 
finger,  is  not  so  readily  performed.  The  patient  when 
seated  in  front  of  the  operator  must  be  made  to  bend  the 
head  back,  to  open  wide  the  mouth,  and  to  thrust  out  the 
tongue.  The  right  forefinger  of  the  operator  must  then  be 
passed  rapidly  backward  along  the  roof  of  the  mouth,  and 
then  suddenly  bent  downwards  until  its  tip  comes  in  con- 
tact with  the  epiglottis  and  neighboring  parts.  This  method 
of  examination  is  chiefly  useful  to  detect  the  presence  of 
oedema  glottidis,  and  of  tumors  lying  over  the  orifice  of  the 
larynx,  and  to  remove  foreign  bodies  which  may  have  be- 
come lodged  there. 

Laryngoscopic  Examination. — It  is  not  necessary  here  to 
describe  the  various  forms  of  laryngoscopes  which  have 
been  devised,  and  many  of  which  are  now  in  use  by  different 
observers.  For  general  purposes  it  suflices  to  have  three  or 
four  throat  mirrors  of  different  sizes,  which  are  plane  mirrors, 
usually  round  in  shape,  attached  at  an  angle  to  their  metallic 
rods,  which  fit  into  an  ivory  or  wooden  handle,  and  are  there 
secured  by  means  of  a  screw.  It  is  of  some  importance  to 
reserve  one  of  these  mirrors  for  syphilitic  cases.  The  light 
used  for  illumination  may  be  sunlight  or  daylight,  but  in 
this  climate  it  is  better  to  trust  to  the  artificial  light  of  a 
good  lamp.  The  rays  of  light  are  reflected  into  the  patient's 
mouth  from  a  concave  mirror,  which  is  most  usually  secured 
to  the  forehead  of  the  operator  by  means  of  a  circular  band 
passing  round  the  head.  This  mirror  has  a  small  opening 
in  the  centre,  which  is  placed  so  as  to  correspond  to  tne 


RESPIRATORY   SYSTEM.  I3I 

eye  of  the  observer,  and  through  which  he  can  see  the  laryn- 
geal mirror. 

Method  of  Examinatio7i. — The  patient  must  be  seated  op- 
posite and  very  close  to  the  observer,  and  the  fauces  illu- 
minated from  the  mirror  on  the  forehead  of  the  latter.  The 
light  should  be  placed  near  the  side  of  the  patient's  head, 
at  the  level  of  and  slightly  behind  the  mouth.  The  patient 
having  been  made  to  open  his  mouth  widely,  and  to  pro- 
trude his  tongue,  grasping  its  point  between  the  thumb 
and  forefinger  of  his  right  hand,  protected  with  a  handker- 
chief or  napkin,  the  observer  now  takes  up  the  laryngeal 
mirror,  which  has  been  previously  warmed,  in  the  right 
hand  (he  ought  to  be  able  to  use  the  left  hand  also  for  this 
purpose),  and,  holding  it  as  one  holds  a  pen,  he  passes  it 
rapidly  into  the  patient's  mouth,  and,  carefully  avoiding 
unnecessary  contact  with  the  surface  of  the  tongue  or  pal- 
ate, presses  its  posterior  surface  upon  the  uvula.  It  will 
be  found  to  increase  the  steadiness  of  this  movement  if  the 
little  finger  of  the  operator  be  allowed  to  rest  on  the  pa- 
tient's cheek  at  the  angle  of  the  mouth.  With  the  mirror 
lying  in  this  position  the  larynx  usually  comes  more  or  less 
perfectly  into  view,  when  the  patient  is  desired  to  ejaculate 
"ah."  By  slight  movements  of  the  mirror  the  whole  of  the 
larynx  can  be  explored.  Turning  the  laryngeal  mirror 
downwards,  there  come  into  view  in  succession  the  back  of 
the  tongue,  the  upper  surface  of  the  epiglottis  with  the 
glosso-epiglottidean  ligaments,  the  arytenoid  cartilages,  the 
false  and  the  true  vocal  cords,  the  ventricles  of  the  larynx, 
the  rings  of  the  trachea,  sometimes  even  as  far  down  as  the 
bifurcation.  There  are  several  difficulties  which  may  arise 
in  the  course  of  laryngoscopic  examination.  Apart  from 
the  obstruction  occasioned  by  enlarged  tonsils,  the  observer 
may  have  to  combat  incessant  attempts  to  retch,  caused  by 
the  contact  of  the  laryngeal  mirror  with  the  throat,  espe- 
cially when  that  region  is  sensitive.  This  can  only  be  over- 
come by  patiently  accustoming  the  parts  to  the  abnormal 
irritation  by  means  of  repeated  examination.  In  other 
cases  the  back  part  of  the  tongue  may  arch  upwards  to 
such  an  extent  as  to  shut  out  the  view.  Very  frequently 
this  difficulty  disappears  when  the  patient  is  directed  to 
say  "  ah,"  but  if  this  measure  fails,  then  the  organ  may  be 
forcibly  depressed  by  means  of  a  spatula. 

It  is  to  be  borne  in  mind  that  the  parts  reflected  in  the 
right  and  left  part  of  the  mirror  correspond  to  XhQ  patient's 


132  MEDICAL  DIAGNOSIS. 

left  and  right,  and  that  the  more  anterior  structures  are 
seen  in  the  upper  part  of  the  mirror,  the  more  posterior  in 
the  lower. 

Having  carefully  examined  the  various  portions  of  the 
larynx,  which  may  be  brought  into  view  by  changing  the 
position  of  the  mirror,  it  is  perhaps  best  to  systematize 
the  information  gained  by  grouping  the  facts  under  some 
such  heads  as  the  following  : 

(i.)  Changes  in  Color. — In  the  normal  larynx  the  mucous 
membrane  generally  has  a  clear  red  appearance,  while  the 
epiglottis  is  slightly  yellow,  and  the  true  vocal  cords  stand 
out  distinctly,  having  a  clear  pearly-white  color.  In  anae- 
mic conditions,  the  interior  of  the  larynx  generally  becomes 
paler  in  color;  whereas  in  acute  catarrhal  conditions  the 
parts  assume  an  intense  red,  especially  the  epiglottis,  and 
even  the  true  cords  lose  their  whiteness  and  become  swol- 
len, red,  and  injected.  In  more  chronic  catarrh  the  tint 
assumed  is  not  so  bright,  but  is  more  grayish  red.  In  cases 
of  croup  the  false  membrane  can  sometimes  be  seen  in  the 
larynx. 

(2.)  Ulceration. — If  ulcers  are  visible,  their  position,  size, 
and  general  features  should  be  noted. 

(3.)  Tumefaction. — Swelling  of  the  parts  round  the  glottis 
(oedema  glottidis)  may  occur  from  a  variety  of  causes,  and 
the  early  recognition  of  this  very  dangerous  condition  by 
means  of  the  laryngoscope  is  of  the  utmost  importance. 
New  formations  are  sometimes  met  with,  and  their  size, 
character,  and  seat  must  be  carefully  noted. 

(4.)  Foreign  bodies. — In  children,  in  particular,  the  laryngo- 
scope is  of  great  service  in  showing  where  a  foreign  body 
has  lodged,  and  in  aiding  in  its  removal. 

(5.)  Movements  of  the  Larynx.,  particularly  of  the  True  Cords. 
— The  larynx  is  supplied  by  means  of  two  nerves,  the 
superior  and  the  inferior  (or  recurrent  laryngeal  branches 
of  the  vagus).  Paralysis  of  these  nerves  produces  different 
symptoms,  and.  must  be  considered  separately.  The  move- 
ments of  the  cords  are  very  readily  discerned.  During  in- 
spiration they  move  apart,  so  as  to  leave  a  very  free  passage 
for  the  air,  while  during  expiration  near  each  other  again. 
These  movements  are,  of  course,  exaggerated  during  forced 
breathing.  When  a  note  is  sung  the  vocal  cords  of  each 
side  approach  very  close  to  each  other,  so  as  almost  to 
come  in  contact. 


RESPIRATORY    SYSTEM.  I33 

Paralysis  of  the  Superior  Laryngeal  Nerve  causes  anaesthe- 
sia of  the  mucous  membrane  of  the  upper  and  middle 
portions  of  the  laryngeal  cavity,  along  with  paralysis  of 
the  crico-thyroid  muscle,  and  of  the  depressors  of  the  epi- 
glottis (thyro  and  aryteno-epiglottidean  muscles).  As  a 
consequence  of  this  the  epiglottis  is  immovable,  and  ap- 
plied to  back  of  the  tongue;  and  as  without  the  action  of 
the  crico-thyroid  the  vocal  cords  cannot  be  rendered  tense, 
the  voice  is  hoarse  and  deep,  and  (according  to  Mackenzie) 
the  cords  can  be  seen  ta  be  loose,  their  centre  being  visibly 
depressed  during  inspiration,  and  elevated  during  expira- 
tion. The  paralysis  of  the  epiglottis  allows  particles  of 
food  to  enter  the  larynx.  Paralysis  of  the  superior  laryn- 
geal nerve  is  usually  the  result  of  diphtheria. 

Paralysis  of  the  Inferior  (or  Recurrent)  Laryngeal  Nerve 

may  be  due  to  central  degenerative  changes  in  the  floor  of 
the  fourth  ventricle  (in  bulbar  paralysis,  and  other  affec- 
tions of  the  pons  and  medulla),  but  it  is  much  more  fre- 
quently the  result  of  lesions  of  the  nerve  trunks  in  their 
course.  Whilst  the  two  recurrent  nerves  are  equally  liable 
to  suffer  from  the  pressure  of  such  tumors  as  bronchocele, 
cancer  of  the  upper  part  of  the  oesophagus,  etc.,  it  is  to  be 
carefully  borne  in  mind  that  the  course  of  the  left  nerve 
exposes  it  specially  to  injury  from  the  pressure  of  aortic 
aneurisms,  while  the  right  recurrent  is  frequently  paralyzed 
by  being  involved  in  thickening  of  the  right  pleusa  with 
which  it  lies  in  contact — a  condition  met  with  in  phthisis 
of  the  right  apex. 

Bilateral  Recurrent  Paralysis. — In  this  very  rare  condition 
the  vocal  cords  are  perfectly  immobile,  and  may  be  seen  to 
have  assumed  what  Von  Ziemssen  calls  the  cadaveric  posi- 
tion, that,  namely,  which  is  found  in  the  dead  subject  ;* 
there  is  absolute  loss  of  voice,  and  the  patient  speaks  in  a 
whisper,  and  that  with  considerable  exertion  and  difficulty, 
owing  to  the  great  expenditure  of  air  required  on  account 
of  the  width  of  the  glottis.  For  the  same  reason  coughing 
becomes  extremely  difficult,  but  there  is  little  or  no  dyspnoea. 
Ufiilateral  Recurrent  Paralysis. — In  this  condition  the 
vocal  cord  on  the  paralyzed  side  occupies  the  cadaveric 
position  already  described,  while  the  healthy  cord  possesses 

*  The  cords  lie  about  midway  between  the  lateral  position  of  deep  in- 
spiration and  the  median  one  of  phonation. 


134  MEDICAL   DIAGNOSIS. 

its  normal  range  of  movement,  and,  indeed,  rather  exceeds 
this,  crossing  the  median  line  to  some  extent  so  as  to  com- 
pensate for  its  paralyzed  neighbor.  The  voice  is  impure, 
metallic,  and  high  pitched,  and  readily,  as  Traube  pointed 
out,  passes  into  a  falsetto. 

Paralysis  of  the  Individual  Muscles  supplied  by  the  Inferior 

Pharyngeal  Nerve. 

(i.)  Posterior  Crico- Arytenoid  Muscles. — These  muscles 
have  for  their  function  the  widening  of  the  glottis,  which  is 
necessary  for  inspiration.  When  they  are  both  paralyzed 
a  condition  ensues  which  is  one  of  the  gravest  met  with  in 
connection  with  laryngeal  pathology.  The  two  vocal  cords 
are  then  found  to  be  lying  close  to  each  other  in  the  middle 
line,  and  from  this  position  they  do  not  move  even  during 
inspiration.  The  consequence  is,  that  when  the  paralysis 
is  complete  there  is  very  well  marked  inspiratory  dyspnoea, 
and  this  not  merely  because  the  vocal  cords  cannot  be 
drawn  asunder  by  the  paralyzed  muscles,  but  because  the 
rush  of  air  forces  them  still  more  closely  together.  While 
inspiration  is,  therefore,  noisy,  the  voice  is  usually  unaf- 
fected. 

When  only  one  of  the  posterior  crico-arytenoid  muscles 
is  paralyzed,  the  vocal  cord  of  the  affected  side  lies  in  the 
middle  line;  the  voice  is  impure,  but  the  glottis  being  com- 
paratively wide,  it  is  only  with  forced  inspiration  that  there 
is  any  noise. 

(2.)  Arytenoid  Muscles. — These  muscles  having  for  their 
function  the  closure  of  the  posterior  third  of  the  glottis,  it 
will  be  easily  understood  that  when  they  are  paralyzed  both 
vocal  cords  lie  during  phonation  in  their  normal  position 
for  the  anterior  two  thirds  of  their  length,  while  at  the  pos- 
terior end  of  the  glottis  an  open  triangle  is  left  through 
which  air  escapes  unhindered.  As  a  consequence  of  this 
the  voice  is  hoarse  and  impure. 

(3.)  Internal  Thyro- Arytenoid  Muscles. — The  action  of  these 
muscles  is  to  render  the  vocal  cords  tense,  and  thereby  to 
close  the  glottis.  When  one  is  paralyzed,  the  cord  of  the 
corresponding  side  is  lax,  and  shows  a  slight  concave  ex- 
cavation of  its  inner  edge.  When  the  paralysis  is  bilateral, 
this  excavation  is  of  course  found  in  both  cords;  the  voice 
becomes  hoarse,  and  speaking  difficult. 

The  symptoms  of  individual  paralysis  of  other  muscles- 
of  the  larynx  have  not  yet  been  clearly  ascertained. 


RESPIRATORY  SYSTEM.  1 35 

CHAPTER  XV. 

Respiratory  System — (continued), 

INSPECTION. 

In  order  to  determine  the  position  of  any  particular 
point  on  the  thoracic  wall  for  the  purpose  of  description  or 
record,  the  thorax  has  been  divided  arbitrarily  into  certain 
regions,  which  may  be  grouped  in  the  following  manner: 

T.  Median  or  sternal  groups  bounded  on  either  side  by  the 
sternal  border,  which  comprises — 

Supra-sternal  notch. 

Superior  sternal  region. 

Inferior  sternal  region.  The  two  last  regions 
are  separated  by  a  horizontal  line  correspond- 
ing to  the  level  of  the  lower  border  of  the 
third  costal  cartilage. 

2.  Antero-lateral group,  bounded  internally  by  the  sternal 
border,  and  externally  by  a  line  which  commences  at  the 
first  ring  of  the  trachea,  runs  diagonally  outwards  to  the 
acromion  process,  and  then  falls  vertically  downwards. 
This  group  comprises — 

(a.)  Supra-clavicular  region  lying  above  the  upper 
edge  of  the  clavicle. 

{b.)  Clavicular  region,  corresponding  to  the  inner 
half  of  the  clavicle. 

{c.)  Infra-clavicular  region,  from  the  clavicle  to  the 
lower  border  of  the  third  rib. 

(d.)  Mammary  region,  from  the  third  to  the  sixth 
rib. 

(e.)  Infra-mammary  region,  from  the  sixth  rib  down- 
wards. 

3.  The  lateral  group  corresponds  to  the  axilla,  being 
bounded  anteriorly  by  the  vertical  acromial  line,  which 
limits  the  antero-lateral  group,  and  posteriorly  by  the 
axillary  border  of  scapula.     This  group  comprises — 


136  MEDICAL  DIAGNOSIS.  t 

!a.)  Axillary  region. 
d.)  Infra-axillary   region,   which  is   separated   from 
the  former  by  a  horizontal  line  at  the  level  of 
the  sixth  rib. 

4.  Posterior  group,  bounded  externally  by  the  axillary 
border  of  the  scapula,  and  internally  by  the  middle  line 
posteriorly.     The  members  of  this  group  are — 

(a?)  Supra-scapular  region,  lying  above  the  scapula. 
{b?)  Supra-spinous     region,     corresponding     to    the 

supra-spinous  fossa. 
(^.)  Infra-spinous  region,  corresponding  to  the  infra- 

spinous  fossa. 
(^.)  Infra-scapular  region  lying  below  the  scapula. 
(^.)  Inter-scapular  region,  lying  between  the  scapula 

and  the  middle  line. 

Inspection. 

For  the  inspection  of  the  thorax  the  patient  should  be 
placed  in  a  good  light,  if  possible  in  a  sitting  posture  in  an 
unconstrained  position,  and  with  the  surface  of  the  chest 
fully  exposed.  The  general  outline  of  the  thorax  ought  to 
be  viewed  from  the  front,  from  the  back,  from  either  side, 
and  from  above  and  behind,  looking  downwards.  Such 
inspection  gives  information  concerning  (i)  the  form,  and 
(2)  the  movements  of  the  chest. 

I.  The  Form  of  the  Chest. — The  typical  chest  formation, 
which  is,  however,  but  rarely  met  with,  may  be  said  to 
possess  the  following  characteristics.  Conical  in  form, 
with  the  antero-posterior  diameter  shorter  than  the  trans- 
verse, it  is  symmetrical  on  both  sides,  both  generally,  and 
at  each  corresponding  point.  The  supra-  and  infra-clavicu- 
lar regions  are  almost  on  a  level  with  the  clavicles,  and 
from  the  collar-bones  downwards  to  the  fourth  rib  there  is 
on  either  side  a  gentle  convexity.  The  nipple  is  placed  (in 
the  male  and  virgin  female)  on  the  fourth  rib  or  fourth  in- 
tercostal space,  and  from  this  point  downwards  the  chest 
wall  becomes  somewhat  flattened.  In  the  upper  two  thirds 
of  the  chest  the  outlines  of  the  ribs  are  not  well  defined, 
but  below  this  the  thinner  covering  of  muscle  allows  their 
form  to  become  apparent.  The  spine  and  sternum  occupy 
an  almost  exactly  median  position,  and  the  shoulder-blades 
are  symmetrical. 


RESPIRATORY   SYSTEM.  1 37 

From  this  typical  form  there  are  many  deviations  com- 
patible with  health  (physiological  heteromorphisms,  as 
Woillez  *  terms  them),  of  which  the  principal  are  those  as- 
sociated with  the  phthisical  and  with  the  rickety  constitu- 
tions. Many  persons  who  are  predisposed  to  phthisis  show 
a  peculiar  thoracic  conformation  which  has  been  called 
alar,  or  pterygoid,  on  account  of  the  wing-like  projection 
of  the  scapulae.  The  chest  is  long,  narrow,  sometimes  flat- 
tened anteriorly,  the  ribs  oblique,  the  shoulders  sloping, 
and  the  throat  prominent. 

The  occurrence  of  any  obstruction  to  the  respiration  in 
childhood  along  with  rickets  tends  to  produce  the  "pigeon 
breast,"  through  the  yielding  of  the  softened  ribs.  In  this 
form  of  thorax  the  ribs  are  straightened,  and  the  sternum 
thrown  forwards  so  that  a  transverse  section  of  the  chest 
would  approach  a  triangular  form.  Independently,  how- 
ever, of  any  pulmonary  complication,  rickets  may  of  itself 
determine  a  peculiar  thoracic  formation,  when  the  ribs  are 
so  soft  as  not  to  be  capable  of  bearing  the  atmospheric 
pressure  necessarily  thrown  upon  them  during  inspiration. 
A  longitudinal  groove  is  thus  formed  on  either  side  of  the 
sternum. 

Irregular  formation  of  the  thorax  may  also  be  caused  by 
deformities  of  the  spinal  column. 

Changes  in  the  Form  of  the  Thoi'ax  in  Pulmonary  Diseases. 

These  may  be  local  or  general. 

(i.)  Local. — Bulging  is  met  with  in  encapsuled  pleural 
effusions,  in  empyaema,  in  pericardial  effusions,  in  cardiac 
hypertrophy,  and  over  large  cavities  in  the  lung.  Tumors 
of  the  liver  and  spleen  may  also  cause  bulging,  the  former 
at  the  right  side,  the  latter  at  the  left,  and  surgical  affec- 
tions of  the  chest  wall  may  give  rise  to  local  swelling. 
Localized  shrinking  occurs  chiefly  in  connection  with 
phthisis,  when  there  may  be  flattening  in  the  supra-  and 
infra-clavicular  regions.  The  rare  condition  in  which  there 
is  congenital  absence  of  part  of  the  pectoral  muscles  must 
not  be  mistaken  for  flattening. 

(2.)  General. — Bilateral  enlargement  of  the  thorax  results 
from  pulmonary  emphysema.  This  so-called  barrel-shaped 
chest  is  enlarged  in  all  its  diameters,  rounded,  and  the  in- 

*  Trait/ de  Percussion,  etc.,  p.  415.     Paris,  J879. 


138  MEDICAL  DIAGNOSIS. 

tercostal  spaces  wide.  The  respiratory  movements  are  very 
slight,  and  the  thorax  remains  permanently  in  a  condition 
resembling  that  of  full  inspiration.  Unilateral  enlargement 
may  arise  from  extensive  pneumonia,  from  tumor  affecting 
the  greater  part  of  one  lung  (Eichhorst),  but  it  is  most  evi- 
dent when  effusion  of  fluid  or  gas  takes  place  into  the 
pleural  cavity.  In  pleurisy  with  extensive  effusion  the  di- 
ameter of  the  thorax  on  the  affected  side  is  increased;  the 
intercostal  spaces  are  wide,  and  rise  to  the  level  of  the  ribs, 
or  even  bulge  beyond  them;  the  nipple  is  moved  upwards 
and  outwards,  and  the  heart  is  pressed  over  towards  the 
sound  side  in  the  manner  already  described.  Unilateral 
shrinking  of  the  chest  may  come  on  as  the  result  of  absorp- 
tion of  a  pleural  effusion  when  the  lung  is  not  in  a  condi- 
tion to  expand.  It  is  also  met  with  in  cases  of  pulmonary 
cirrhosis. 

2.  Respiratory  Movements. — In  connection  with  the  act  of 
breathing  we  have  to  note  the  following  points — (i)  its  fre- 
quency, (2)  its  rhythm,  (3)  its  type,  (4)  its  pain  or  difficulty, 
(5)  the  extent  of  the  movements. 

(i).  The  Frequency  of  Respwation. — The  respiratory  move- 
ments are  so  much  under  the  control  of  the  will  that  the 
physician  should  endeavor  to  estimate  their  rapidity  with- 
out the  knowledge  of  the  patient.  This  is  best  done  by 
holding  the  fingers  upon  the  radial  artery,  as  if  to  count  its 
pulsations,  while  the  patient's  hand  rests  upon  the  epigas- 
trium and  rises  and  falls  with  the  respiration.  Whilst  in 
new-born  children  the  breathing  may  be  at  the  rate  of  forty- 
four  per  minute,  in  the  adult  male  it  averages  from  sixteen 
to  twenty-four,  but  is  slightly  more  rapid  in  the  female. 
It  is  increased  in  rapidity  by  exertion,  and  after  meals,  and 
is  slower  in  the  recumbent  posture  than  when  sitting  or 
standing.  It  reaches  its  lowest  rate  during  sleep.  It  is 
most  important  to  note  the  ratio  between  respiration  and 
pulse  which  is  usually  i:  4,  but  may  vary  from  1:1  to  1:7. 

Pathologically,  the  act  of  breathing  is  rendered  slow  by 
stenosis  of  the  larynx  (as  in  croup),  and  by  any  cerebral 
disease  which  induces  pressure- upon  the  respiratory  centre 
in  the  medulla.  More  common,  however,  is  increase  in  fre- 
quency, which  may  arise  in  a  variety  of  ways — (i)  When  the 
act  of  respiration  causes  pain  (as  in  pleurisy  and  peritonitis); 

(2)  reflexly,  as  a  result  of  pain  situated  in  other  organs; 

(3)  from  chemical  changes  in  the  blood,  such  as  are  met 


RESPIRATORY   SYSTEM.  1 39 

with  in  anaemia  and  in  lucocythaemia;  (4)  from  mechanical 
hindrance  to  the  entrance  of  air  into  the  pulmonary  air-cells, 
•which  may  exist  in  the  larynx,  trachea,  bronchi,  or  lung  tis- 
sue; or  may  result  from  pressure  on  the  lung  from  without 
by  means  of  pleural  effusion,  ascites,  meteorism,  etc.;  (5) 
disturbance  of  the  circulation  through  the  lungs,  which  may 
arise  from  a  variety  of  conditions,  such  as  valvular  disease, 
pulmonary  embolism,  etc.;  (6)  from  fever  (the  increased 
temperature  of  the  blood  over-exciting  the  respiratory  cen- 
tre— the  so-called  "heat-dyspnoea");  (7)  from  certain  ner- 
vous disorders,  such  as  hysteria. 

(2.)  The  Rhythm  of  the  RespU'atory  AT ove7ne7its. — In  health 
the  rhythm  of  the  breathing,  when  uninfluenced  by  will,  is 
very  regular,  expiration  following  inspiration  immediately, 
and  being  somew^hat  shorter  in  duration,  aft^r  which  there 
is  short  a  pause.  Walshe*  calculates  that  if  the  whole  act  be 
taken  as  equal  to  10,  then  the  inspiration  maybe  estimated 
as  5,  the  expiration  as  4,  and  the  pause  as  i.  These  rela- 
tions, however,  only  hold  good  in  health.  In  disease  either 
the  expiration  or  the  inspiration  maybe  altered  induration 
usually  at  the  expense  of  the  pause.  Inspiration  is  length- 
ened whenever  an  obstacle  to  the  entrance  of  air  exists  in 
the  larynx  or  trachea,  and  is  particularly  well  marked  in 
cases  of  paralysis  of  the  posterior  crico-arytenoid  muscles. 
Expiration  on  the  other  hand  is  prolonged  when  any  ob- 
struction to  the  exit  of  air  exists  in  any  part  of  the  respir- 
atory tract,  as  is  the  case  in  vesicular  emphysema.  The 
rhythm  of  the  respiratory  movements  frequently  becomes 
jerking  and  unequal,  particularly  in  children  where  the  flex- 
ible chest  wall  yields  to  the  external  atmospheric  pressure 
during  inspiration,  when  any  obstruction  to  the  free  en- 
trance of  air  exists  in  the  larynx,  trachea,  or  bronchi. 

One  of  the  most  peculiar  alterations  in  rhythm  is  seen  in 
the  Cheyne-Stokes  breathing,  when  the  sequence  of  the  re- 
curring respiratory  acts  is  broken  by  the  occurrence,  at  in- 
tervals of  about  I  to  i^  minute,  of  pauses,  during  which  re- 
spiration entirely  ceases.  These  pauses,  which  last  from  \ 
to  f  of  a  minute,  are  followed  by  the  gradual  resumption  of 
the  respirations,  which,  at  first  short  and  superficial,  grow 
gradually  deeper  up  to  the  point  of  dyspnoea,  after  which 
the  breathing  becomes  again  shallower  until  the  next  pause 
is  reached,  and  so   on.     The  exact  manner  in  which   this 

__*  "  Diseases  of  the  Lungs,"  4th  edition,  p.  14. 


I40  MEDICAL  DIAGNOSIS. 

peculiar  rhythm  is  produced  is  somewhat  doubtful.  One 
most  important  factor  seems  to  be  a  deficient  supply  of 
oxygen  to  the  respiratory  centre  in  the  medulla.  The 
Cheyne-Stokes  breathing  is  met  with  in  many  cerebral  dis- 
eases, in  uraemia,  in  fatty  degeneration,  in  valvular  disease 
of  the  heart,  and  is  usually  one  of  the  immediate  precursors 
of  a  fatal  termination. 

(3.)  The  Type  of  the  Respiratory  Movements. — In  men  the 
respiratory  movements  chiefly  affect  the  abdominal  walls 
and  the  lower  ribs  (costo-abdominal  type),  while  in  women 
the  diaphragm  does  not  take  so  prominent  a  part  in  the  act 
of  breathing,  and  the  movement  is  in  great  measure  con- 
fined to  the  upper  part  of  the  thorax  (costal  type).  In  dis- 
ease, however,  these  conditions  may  be  changed,  for  anything 
which  interferes  with  the  movements  of  the  diaphragm 
(such  as  ascites,  peritonitis,  and  many  other  affections  of  the 
abdomen)  will  in  a  man  change  the  type  of  breathing  into 
the  purely  costal,  whilst  the  latter  type  of  breathing  maybe 
lost  in  a  woman  when  there  is  some  painful  affection  of  the 
thoracic  organs  which  obliges  the  respiration  to  be  chiefly 
abdominal. 

(4.)  Pain  and  Difficulty  in  Breathing. — Pain  in  relation  to 
the  organs  of  respiration  has  already  been  mentioned,  and 
need  not  detain  us  here.  When  present,  it  is  usually, 
though  not  always,  aggravated  by  the  respiratory  move- 
ments. 

Dyspnoea^  or  difficulty  of  breathing,  may  be  of  a  purely 
nervous  or  subjective  kind.  The  rate  is  then  usually  nor- 
mal, and  the  air  can  be  heard  to  be  freely  entering  the  lung, 
while  all  the  causes  of  objective  dyspnoea  are  absent.  This 
symptom  usually  occurs  in  hysterical  women.  In  true  ob- 
jective dyspnoea  the  respirations  are  deep  and  long  drawn, 
and,  as  already  mentioned,  either  the  inspiration  or  the  ex- 
piration may  be  interfered  with.  In  the  former  case,  all 
the  accessory  muscles  of  inspiration  are  called  into  play, 
and  their  contractions  form  a  very  striking  feature  in  such 
cases.  These  include  hot  merely  the  dilators  of  the  thorax, 
such  as  the  sterno-mastoids,  the  scaleni,  the  pectorals,  etc., 
but  also  those  muscles  which  dilate  the  nostrils,  elevate  the 
soft  palate,  depress  the  larynx,  and  open  the  glottis.  In 
order  to  the  effective  action  of  these  accessory  muscles,  the 
patient  has  to  assume  the  sitting  posture  (orthopnoea),  and, 
provided  that  he  is  not  comatose,  the  degree  of  difficulty  of 
breathing  which  is  present  may  be  more  or  less  accurately 


RESPIRATORY   SYSTEM.  I4I 

estimated,  according  as  the  position  assumed  approaches 
the  sitting  posture. 

(5).  The  Extetit  of  the  Movements. — In  the  barrel-shaped 
chest  which  accompanies  vesicular  emphysema,  there  is,  as 
has  been  already  said,  diminution  of  the  movements  of  the 
chest  in  all  directions.  More  important,  however,  for  the 
purposes  of  diagnosis,  are  those  localized  inequalities  in  the 
range  of  the  movements  which  are  occasionally  met  with. 
When  one  lung  is  compressed  by  reason  of  pleuritic  effu- 
sion, or  is  from  any  other  cause  rendered  incapable  of  ex- 
pansion, the  thoracic  movements  on  that  side  become  de- 
fective. Phthisical  consolidation  at  the  apices  gives  rise  to 
deficient  movement  in  the  upper  part  of  the  chest,  as  com- 
pared with  the  lower;  while  in  cases  of  stenosis  of  the 
larynx  and  in  emphysema,  the  opposite  condition  obtains, 
for  then  during  the  expansion  of  the  chest  there  is  depres- 
sion of  the  lower  intercostal  spaces,  of  the  epigastrium,  in 
the  supra-clavicular  regions,  and  in  the  supra-sternal 
notch. 


CHAPTER  XVI. 

Respiratory  System. — {continued). 

PALPATION. 

By  laying  the  hand  flat  upon  the  thorax  and  palpating  its 
walls,  information  may  be  obtained  regarding  the  form  and 
movements  of  the  chest,  the  presence  or  absence  of  fremi- 
tus, of  fluctuation,  and  of  certain  pulsatory  movements 
other  than  those  already  referred  to  in  connection  with  the 
circulatory  system. 

1.  The  Form  of  the  Thorax. — The  general  form  of  the 
chest  is  best  appreciated  by  means  of  simple  inspection; 
but  localized  changes  in  shape  may  be  recognized  by  pal- 
pation. 

2.  The  Movements  of  the  Thorax. — The  information  ob- 
tained by  inspection  may  be  supplemented  by  laying  the 


142  .  MEDICAL  DIAGNOSIS. 

hands  on  the  thorax,  and  estimating  the  local  movements 
of  expansion  and  elevation  at  particular  parts. 

3.  Vocal  Fremitus,  or  that  vibration  of  the  chest  wall  which 
may  be  felt  in  a  healthy  person  while  speaking,  is  of  con- 
siderable diagnostic  importance.  Under  the  vocal  cords  in 
the  larynx  lies  an  air  column,  which  extends  through  the 
trachea  and  bronchi  to  the  pulmonary  alveoli,  and  which  is 
set  in  vibration  when  the  vocal  cords  vibrate,  and  through 
the  bronchial  walls  and  lung  tissue  the  thrill  so  generated 
is  conducted  to  the  thoracic  parieties.  It  is  not  difficult  to 
understand  the  conditions  under  which  its  intensity  be- 
comes increased  or  diminished.  The  thickness  of  the 
thoracic  wall  has  an  important  influence,  the  thrill  being 
more  distinct  in  emaciated  subjects  than  in  those  who  have 
much  deposit  of  fat  underneath  the  skin.  The  intensity  of 
the  vocal  fremitus  also  depends  upon  the  loudness  of  the 
tone  spoken,  and  upon  the  depth  of  its  pitch;  and  finally, 
it  must  not  be  forgotten  that  it  is  more  distinct  in  men 
than  in  women  and  children,  and  that  the  thrill  on  the  right 
side  is  almost  invariably  greater  than  that  on  the  left,  this 
being  .accounted  for  by  the  larger  calibre  of  the  right  bron- 
chus. 

In  disease  the  vocal  fremitus  may  be  diminished  or  in- 
creased. 

(i.)  Diminished. — Any  condition  which  blocks  up  the 
bronchi,  such  as  collection  of  mucus  or  pus,  or  compres- 
sion by  means  of  tumors,  will  produce  a  diminution  of  the 
vocal  fremitus  over  the  corresponding  part  of  the  chest 
wall.  More  extensive  loss  of  the  thrill  is  met  with  where 
effusion  of  fluid  or  gas  into  the  pleural  cavity  has  taken 
place.  If  the  effusion  be  extensive,  the  vocal  fremitus  may 
be  entirely  lost;  and  should  the  lung  be  bound  down  by 
extensive  adhesions,  the  fremitus  may  not  be  regained  even 
after  the  entire  absorption  of  the  effusion. 

(2.)  Increased. — When  infiltration  takes  place  into  the  air- 
cells  of  the  lung,  the  pulmonary  parenchyma  becomes  at 
once  a  better  conductor  of  the  vocal  vibrations,  and  in  con- 
sequence the  thrill  becomes  intensified.  Such  is  the  case, 
for  example,  in  lobar  pneumonia;  and  where  the  lower  lobe 
is  affected,  the  vocal  fremitus  gives  most  important  aid  in 
distinguishing  that  affection  from  pleural  effusion.  The 
fremitus  is  likewise  increased  where  there  is  phthisical  con,- 
solidation,  particularly  if  cavities  have  formed;  but  should 


RESPIRATORY   SYSTEM.  I43 

a  main  bronchial  branch  leading  to  the  part  have  become 
obstructed,  either  by  pressure  or  by  the  collection  of  mu- 
cus, pus,  or  blood,  the  vocal  thrill  may  be  diminished  or 
lost. 

4.  Pleural,  Bronchial,  and  Cavernous  Thrills. — The  palpat- 
ing hand  may  also  detect  .the  fremitus  occasioned  by  the 
rubbing  together  of  the  roughened  pleural  surfaces  in  cases 
of  pleurisy,  and  large  rales  in  the  bronchi  or  in  cavities  in 
the  lungs  may  communicate  an  appreciable  thrill  to  the 
walls  of  the  chest.  These  are,  however,  of  little  diagnos- 
tic importance,  in  that  they  are  better  appreciated  by  the 
aid  of  auscultation. 

5.  Fluctuation. — When  one  side  of  the  thorax  is  distended 
with  fluid,  fluctuation  may  occasionally  be  detected  in  it, 
more  particularly  and  importantly  in  empysema. 


CHAPTER  XVII. 

Respiratory  System — (continued). 

MENSURATION. 

Mensuration,  which  is  intended  to  render  precise  the  in- 
formation which  may  be  gained  by  inspection  and  palpa- 
tion, and  which  in  some  of  its  developments  passes  much 
beyond  these,  is  performed  by  the  aid  of  a  variety  of  in- 
struments which  fail  to  be  described  in  detail. 

I.  The  Tape-Measure  is  used  to  ascertain  the  circumfer- 
ence of  the  chest,  which,  at  the  level  of  the  nipples  and  at 
the  end  of  expiration,  measures  in  the  healthy  male  adult 
about  thirty-two  or  thirty-three  inches.  A  full  inspiration 
increases  this  figure  by  from  two  to  five  inches,  while  in 
quiet  respiration  the  inspiration  position  exceeds  the  ex- 
piration by  about  half  an  inch.  Unfortunately  the  circum- 
ferential measurement  of  the  chest  is  of  comparatively  lit- 
tle diagnostic  value,  as  very  great  variations  are  met  with 
in  health.  Much  more  important  is  it  to  learn  the  relative 
size  of  the  two  sides  of  the  chest.     This   is  most  conven- 


144  MEDICAL   DIAGNOSIS. 

iently  done  by  joining  two  tapes  at  the  commencement  of 
their  scales,  and  fixing  this  point  of  junction  over  the  ver- 
tebral column.  Each  side  of  the  chest  has  thus  a  tape  for 
itself,  and  the  two  measurements  can  be  simultaneously 
made  and  compared.  In  right-handed  persons  the  right 
half  of  the  chest  is  about  half  an  inch  larger  in  circumfer- 
ence than  the  left;  while  in  those  who  are  left-handed  these 
conditions  are  either  reversed,  or,  what  is  more  common, 
the  two  sides  of  the  chest  are  practically  identical  in  size. 
Unilateral  enlargement  and  shrinking,  the  result  of  dis- 
ease, are  very  readily  detected  by  means  of  such  measure- 
ment. 

2.  Callipers. — Various  diameters  of  the  chest  may  be 
measured  by  means  of  a  pair  of  common  steel  callipers. 
Of  these  the  most  important  is  undoubtedly  the  antero- 
posterior (sterno-vertebral),  which  in  the  phthinoid  chest  is 
much  diminished — the  normal  measurement  being  9  to  10 
inches.  More  difficult  is  it  to  obtain  exact  measurements 
of  the  antero-posterior  diameter  of  either  apex.  For  this 
purpose,  one  point  of  the  callipers  is  to  be  applied  im- 
mediately below  the  centre  of  the  clavicle,  and  the  other  on 
the  spine  of  the  scapula  at  a  similar  distance  from  the 
middle  line.  If  great  care  be  taken,  sufficiently  reliable 
results  may  in  this  way  be  obtained,  when  it  will  be  found 
almost  invariably,  that  in  healthy  persons  the  right  meas- 
urement very  slightly  exceeds  the  left.  An  excess  of  even 
a  fourth  of  an  inch  on  the  right  side  indicates,  however, 
morbid  depression  on  the  left,  while,  if  the  left  be  in  excess 
by  that  amount,  there  is  still  more  conclusive  evidence  of 
contraction  on  the  right  side.* 

3.  Cyrtometer. — This  instrument,  devised  by  Woillez, 
consists  of  a  series  of  small  pieces  of  whalebone,  so  artic- 
ulated together  as  to  form  a  stiff  chain  which,  when  closely 
applied  to  the  walls  of  the  thorax,  retains  the  curves  given 
to  it,  and  which,  when  removed  and  laid  upon  a  large  sheet 
of  paper,  permits  of  these  curves  being  marked  out  on  the 
paper.  The  instrument  may  be  more  simply  constructed 
of  tw(^  pieces  of  lead  wire,  joined  together  by  means  of  a 
piece  of  india-rubber  tubing,  and   in   this  form  it  is  very 

*  Walshe,  "Diseases  of  the  Lungs,"  4th  ed.,  p.  33. 


RESPIRATORY   SYSTEM.  I45 

easily  used,  and  the  outline  of  the  chest  wall  can  be  most 
accurately  depicted  by  its  means. 

So  far  I  have  described  those  instruments  which  are 
fitted  to  give  us  measurements  of  the  chest  when  at  rest, 
and  I  now  proceed  to  consider  those  which  have  for  their 
design  the  measurement  or  registration  of  the  thoracic 
movements. 

4.  Thoracometer,  or  Chest-Measurer. — This  instrument,  as 
constructed  by  Sibson,*  consists,  in  its  essential  parts,  of  a 
dial  which  measures  accurately  the  vertical  movements  of  a 
small  rod,  which  is  applied  to  the  surface  of  the  chest  by 
means  of  a  spring.  Owing  to  various  errors  which  are 
necessarily  present  in  the  readings  obtained,  this  instru- 
ment has  never  come  into  general  use. 

5.  Stethograph. — The  double  stethograph  of  Riegel  ap- 
pears to  be  more  trustworthy  in  its  results  than  the  last- 
named  instrument.  Two  levers,  which  are  acted  upon  by 
the  movements  of  the  chest  walls  at  two  different  points, 
are  so  arranged  as  to  record  their  results  on  a  strip  of  paper, 
travelling  horizontally  by  clockwork.  The  tracings  so  ob- 
tained enable  us  to  analyze  the  respiratory  movements  in  a 
much  more  exact  manner  than  can  be  done  by  means  of 
any  other  instrument.  Pathologically,  the  most  striking 
changes  are  those  in  which  there  is  an  impediment  to  the 
free  entrance  or  exit  of  air.  For  example,  where  the  larynx 
or  trachea  is  stenosed,  while  the  expiratory  curve  is  normal, 
the  inspiratory  is  much  prolonged.  The  reverse  is  the  case 
in  emph3^sema,  where  the  expiratory  curve  is  prolonged  and 
irregular. 

I  now  come  to  the  third  class  of  instruments  of  mensura- 
tion, those,  namely,  which  deal  with  the  air  passing  into  and 
out  of  the  chest. 

6.  Spirometer. — Hutchinson's  spirometer  consists  of  a 
gasometer  properly  poised  and  adjusted,  into  which  the 
patient  expires  forcibly  through  an  elastic  tube,  and  which 
is  arranged  so  as  to  measure  the  amount  of  expired  air. 
The  "vital  capacity"  varies  with  age,  stature,  and  sex,  but 
when  allowances  have  been  made,  it  may  be  said,  as  a 
general  rule,  that  a  diminished  quantity  of  air  is  expired 
when  there  is  stenosis  of  larynx,  trachea,  or  bronchi,  inter- 

*  Medico-Chirurgical  Transactions,  1858. 


146 


MEDICAL  DIAGNOSIS. 


ference  with  the  free  movement  of  the  thoracic  walls,  or 
diminution  of  the  respiratory  surface  of  the  lungs.  Of 
these  diseases  the  most  striking  in  its  results  is  undoubtedly 
phthisis. 

Hutchinson  gives  the  following  table  of  the  results  he 
obtained  from  very  numerous  observations: 


Capacity  of 

Early 

Advanced 

Stature. 

Healthy 

Stage  of 

Stage  of 

Males. 
Cubic  Inches. 

Consumption. 

Consumption. 

Cubic  Inches. 

Cubic  Inches. 

From  5 

feet 

to  5 

feet  I  inch, 

174 

117 

82 

'     5 

"    I  inch  to  5 

'«    2     " 

182 

122 

86 

'     5 

"    2     * 

'     to  5 

"    3    " 

190 

127 

89 

'     5 

"    3     ' 

'    to  5 

"    4    " 

198 

133 

93 

'     5 

"    4     ' 

'     to  5 

"    5     " 

206 

138 

97 

'     5 

"    5     ' 

'     to  5 

..    5    .. 

214 

143 

100 

'     5 

"    6     ' 

*     to  5 

"    7     " 

222 

149 

104 

'     5 

"    7     ' 

'    to  5 

..    8    " 

230 

154 

108 

'     5 

"    8     ' 

*     to  5 

"    9    " 

238 

159 

112 

'     5 

"    9     ' 

'     to  5 

"  10    " 

246 

165 

116 

'     5 

"  10     ' 

•     to  5 

..  H      '' 

254 

170 

119 

'     5 

"  II     ' 

'     to  6 

<  i 

262 

176 

123 

It  must,  however,  be  borne  in  mind  that  there  are  many 
fallacies  in  the  use  of  this  instrument.  Some  persons  can- 
not be  made  to  understand  how  to  blow,  others  by  taking 
great  pains  attain  to  higher  figures  than  their  average,  and 
finally,  by  practice,  the  art  of  blowing  is  so  readily  learned 
that  those  accustomed  to  the  instrument  can  raise  the  gas- 
ometer cylinder  to  very  considerable  elevations. 

7.  Pneumatometer. — This  instrument,  by  means  of  which 
the  force  of  expiration  and  inspiration  is  measured,  is  most 
conveniently  used  in  the  form  devised  by  Waldenburg, 
which  consists  o.f  a  simple  mercurial  manometer  connected 
by  means  of  an  elastic  tube  with  a  mouthpiece  which  fits 
accurately  and  tightly  over  the  mouth  and  nose  of  the 
patient.  When  the  patient  expires  through  the  tube,  the 
column  of  mercury  sinks  in  the  proximal  limb  of  the 
manometer  and  rises  in  the  distal,  while  with  inspiration 
these  movements  are  of  course  reversed,  and  in  either  case 
the  amount  of  displacement  is  to  be  read  off  on  the  scale.* 

*  Since  the  level  of  the  mercury  when  at  rest  corresponds  in  both  limbs 
to  the  zero  of  the  scale,  the  reading  obtained  must,  of  course,  be  doubled 
to  represent  the  true  difference  in  the  level  of  the  two  columns. 


RESPIRATORY   SYSTEM.  I47 

In  a  moderately  well-developed  male  the  inspiratory  pres- 
sure is  from  70  to  100  mm.  of  mercury,  while  the  expiratory 
is  from  90  to  130  mm.,  wliereas  in  the  female  we  get  with 
inspiration  a  pressure  of  50  to  80  mm.  and  with  expiration 
70  to  no  mm.  Of  more  importance  than  the  absolute 
pressure  (which  varies  much  in  different  individuals)  is  the 
difference  between  the  expiratory  and, the  inspiratory  pres- 
sure, and  it  must  be  carefully  borne  in  mind  by  those  who 
use  this  very  valuable  instrument  that  in  healthy  persons 
the  power  of  expiration  exceeds  that  of  inspiration  by  20  to. 
30  mm.  It  is  by  comparing  these  two  pressures  that  the 
most  important  indications  are  obtainable.  Their  relation 
is  altered  in  disease  as  follows: 

Expiratory  pressure  is  increased  in  relation  to  inspiratory  in 
phthisis  (even  at  a  very  early  stage),  in  stenosis  of  the  air 
passages,  in  pulmonary  congestion,  pneumonia,  and  pleurisy, 
and  in  such  abdominal  affections  as  impede  respiration  by 
pressing  the  diaphragm  upwards. 

Expiratory  pressure  is  dimijiished  until  it  becomes  equal  to 
or  below  the  inspiratory  in  pulmonary  emphysema. 

Undoubtedly,  the  importance  of  the  diagnostic  indica- 
tions given  by  the  pneumatometer  in  cases  of  incipient 
phthisis  is  very  considerable,  and  in  all  chronic  chest  com- 
plaints the  instrument  is  of  value  in  indicating  the  progress 
of  the  disease — progressive  or  retrogressive,  as  the  case 
may  be — and  in  estimating  the  results  of  treatment. 

The  space  at  my  disposal  does  not  permit  of  a  descrip- 
tion of  various  other,  less  important,  instruments. 


CHAPTER  XVII. 

Respiratory  System — (continued). 

THEORY    OF    PERCUSSION. 

When  the  surface  of  the  chest  is  percussed  in  the  manner 
which  will  be  described  in  the  next  chapter,  a  sound  is  pro- 
duced which  is  called  the  percussion  note  of  the  part.  This 
term  note  is,  however,  apt  to  mislead,  for  it  is  not  a  simple 
or  pure  note,  not  being  composed  of  a  regular  series  of 
simple  vibrations,  nor  is  it  (as  is  the  case  with  the  sounds 


148  MEDICAL  DIAGNOSIS. 

produced  by  musical  instruments)  made  up  of  one  well- 
marked  basal  or  fundamental  tone  and  a  series  of  higher- 
pitched  upper  partial  tones  which  bear  a  definite  relation 
to  the  basal  or  prime  tone.  The  sound  which  is  heard  on 
percussion  of  the  healthy  chest  is  composed  of  a  large  num- 
ber of  tones,  bearing  no  definite  relation  to  one  another, 
and  in  it  no  definite  or  well-marked  fundamental  note  can 
be  distinguished.  \t  is  very  often  assumed  that  the  note 
produced  on  percussing  the  front  of  the  chest — for  example, 
at  the  level  of  the  second  rib — is  made  up  of  a  distinguish- 
able fundamental  or  prime  tone,  corresponding  in  pitch  to 
the  antero-posterior  diameter  at  the  particular  point  in 
question,  just  as  when  one  blows  across  the  mouth  of  a  test- 
tube  the  prime  tone  obtained  corresponds  in  pitch  to  the 
length  of  the  air  column  contained  in  the  tube.  This  view 
is,  however,  clearly  untenable;  for,  apart  from  the  inherent 
improbability  of  this  particular  air  column  alone  being  set 
in  audible  vibration,  and  not  the  many  others  which  radiate 
from  the  point  of  percussion  to  the  other  limits  of  the  tho- 
racic cavity,  there  is  the  fact  that  in  practice  it  is  impossi- 
ble to  find  what  is  the  real  pitch  of  this  fundamental  or 
prime  tone;  and,  further,  it  is  constantly  noticed  that  the 
apparent  pitch  of  the  percussion  note  varies  enormously 
with  the  variety  of  pleximeter  employed,  and  still  more 
when  the  pleximeter  and  finger  are  compared,  which  would 
not  be  the  case  were  there  a  distinguishable  prime  tone. 

The  percussion  note  is  made  up  of  vibrations  which  are 
derived  from  three  sources. 

1.  T/ie  Vibrations  of  the  Pleximeter. — When  the  finger  is 
employed  as  a  pleximeter,  these  vibrations  are  practically 
inaudible.  In  the  case  of  an  ivory  pleximeter,  however, 
they  are  readily  recognized.  If  the  instrument  be  of  the 
usual  form,  the  vibrations  are  clear  and  relatively  high  in 
pitch;  but  provided  that  the  pleximeter  be  properly  damped 
by  being  firmly  pressed  upon  the  thoracic  wall,  and  be 
struck  with  the  pulp  of  the  finger  alone,  or  with  the  india- 
rubber  of  a  hammer,  the  tone  it  gives  can  be  readily  dis- 
counted by  the  physician. 

2.  The  Vibrations  of  the  Thoracic  Wall. — These  are  of  so 
ill-marked  a  character  (unless  the  point  struck  lie  over  the 
rib  of  a  very  thin  subject)  and  have  so  little  intensity  as  com- 
pared with  the  intrathoracic  note,  that  in  themselves  they 
need  hardly  be  considered,  though,  as  I  will  presently  point 
out,  the  condition  of  the  chest  wall  and  its  vibrations  when 


RESPIRATORY   SYSTEM.  I49 

percussed  have  a  very  important  influence  on  the  character 
of  the  intrathoracic  note. 

3.  The  Vibrations  of  the  Air  in  the  Lmigs. — These  vibra- 
tions constitute  the  important  part  of  the  percussion  note, 
and  must  be  considered  in  some  detail, 

,  When  percussion  is  made  at  any  point  of  the  chest  wall, 
the  air  in  the  lungs  is  set  in  vibration,  and  the  point  which 
is  struck  may  be  considered  as  the  point  of  divergence  of  a 
series  of  radiating  air  columns  whose  lengths  may  be  rep- 
resented by  lines  drawn  from  the  corresponding  point  on 
the  visceral  pleura  to  the  opposite  walls  of  the  thorax  in  all 
directions.  The  lengths  of  these  very  numerous  columns, 
of  course,  differ  considerably;  and  since  an  air  column, 
when  set  in  vibration,  produces  a  note  proportionate  in 
pitch  to  tlie  length  of  the  column,  the  numerous  notes  which 
go  to  make  up  the  percussion  sound  vary  considerably  in 
pitch.  The  pulmonic  septa  also,  in  all  probability,  limit 
the  length  of  certain  of  these  air  columns,  and  in  others 
they  may  determine  nodal  points,  and  in  this  way  cause 
still  greater  differences  in  pitch.  We  have  thus  to  consider 
the  intrathoracic  percussion  sound  as  composed  of  a  large 
number  of  prime  or  fundamental  tones,  which  vary  much 
in  pitch,  and  each  have  an  ascending  series  of  upper  partial 
tones  which  tend,  of  course,  still  further  to  render  the  vi- 
brations of  the  combined  percussion  note  irregular. 

In  a  musical  note  Ave  have  to  recognize  three  distinct 
characters — viz.,  intensity,  pitch,  and  quality;  and  in  rela- 
tion to  the  percussion  sound,  these  must  also  be  consid- 
ered. 

I.  Intensity. — The  intensity  of  a  musical  tone  depends 
upon  the  amplitude  of  the  individual  vibrations  of  which  the 
tone  is  composed.  In  the  case  of  the  drum,  for  example, 
the  intensity  of  the  tone  depends  upon  the  vigor  with  which 
the  drum-head  is  struck.  In  the  same  way,  the  intensity  of 
the  percussion-note  depends,  to  a  considerable  extent,  upon 
the  strength  of  the  stroke.  But  it  must  be  remembered 
that  the  percussion  note,  as  I  have  just  said,  is  composed  of 
a  large  number  of  different  tones,  so  that  its  intensity  in 
any  given  case  depends  also  upon  the  number  of  these 
tones  which  are  produced  by  the  blow.  Thus,  when  the 
greater  part  of  a  lung  is  hepatized,  the  percussion  note  over 
the  healthy  portion  loses  much  of  its  intensity,  because 
there  are  fewer  air  columns  which  can  be  set  in  vibration. 


I50  MEDICAL  DIAGNOSIS. 

The  intensity  of  the  note  is,  therefore,  of  considerable  diag- 
nostic significance. 

2.  Pitch. — The  pitch  of  a  simple  tone,  such  as  that  of  a 
tuning-fork,  depends  upon  the  rate  of  the  vibrations  of 
which  it  is  composed.  In  the  case  of  a  musical  note,  com- 
posed of  a  prime  tone  and  an  ascending  series  of  upper, 
partial  tones  (as,  for  example,  the  note  of  a  stretched  cord), 
the  term  pitch  is  understood  to  mean  the  pitch  of  the  prime 
tone.  It  is  thus  clear  that,  in  regard  to  the  percussion 
sound,  we  cannot,  properly  speaking,  use  the  term  pitch, 
since  it  is  impossible  to  detect  any  fundamental  or  prime 
note.  It  is  evidently  advisable,  however,  to  retain  the 
term,  which  is  so  useful  clinically,  provided  that  in  using  it 
we  carefully  keep  in  mind  that  we  do  not  refer  to  the  pitch 
of  a  basal  note,  which,  as  I  have  said,  does  not  exist,  but  to 
the  general  pitch  of  the  combination  of  tones  which  reach 
the  ear.  If  we  take  an  illustration  from  the  piano,  it  will 
easily  be  seen  what  is  here  meant.  Suppose  that  a  number 
of  notes  at  the  treble  end  of  the  key-board  be  struck  simul- 
taneously with  one  or  two  at  the  base  end,  the  general 
impression  will  be  that  of  a  high-pitched  sound,  and  vice 
versa;  and  so  also  in  the  case  of  the  percussion  sound,  if 
the  number  of  higher  tones  preponderates  greatly  over  that 
of  the  lower  tones  the  general  sound  appears  to  be  high  in 
pitch,  and  vice  versa. 

It  has  been  said  that  when  the  chest  wall  is  struck,  the 
underlying  air  columns  are  set  in  vibration.  This  is  due  in 
great  measure  to  the  direct  transmission  of  the  impulse, 
but  in  some  degree,  at  any  rate,  these  vibrations  seem  to 
arise  by  sympathetic  resonance.  This  demands  a  few  words 
of  explanation. 

If  a  series  of  tuning-forks,  of  different  pitch,  be  in  turn 
sounded  over  the  mouth  of  an  empty  jar,  it  will  probably 
be  found  that  the  series  contains  one  fork  to  which  the  air 
in  the  jar,  so  to  speak,  answers,  which,  when  it  is  sounded, 
throws  the  air  column  into  sympathetic  vibration,  so.  as  to 
reproduce  and  strengthen  its  own  note.  If  the  air  column 
be  measured  it  will  now  be  found  that  its  length  is  exactly 
one-fourth  the  length  of  the  sound-wave  produced  by  the 
fork  in  question.  This  reproduction  and  reinforcement  of 
the  tone  is  termed  resonance.  In  the  same  way,  if  a  corn- 
pound  tone  be  sounded  in  the  neighborhood  of  such  an  air 
column  it  will  be  set  in  sympathetic  vibration  if  the  sound- 
wave of  the  prime  or  any  of  the  upper  partial  tones  hap- 


RESPIRATORY   SYSTEM.  151 

pens  to  bear  the  relation  to  the  length  of  the  column  which 
has  just  been  stated.  Now,  when  the  chest  wall  is  per- 
cussed it  vibrates,  as  I  have  already  pointed  out,  and  gives 
rise  to  a  sound  which  is  usually  inaudible,  and  which,  in 
any  case,  is  of  little  importance.  But  underlying  it  there 
are  numerous  air  columns,  certain  of  which  are  of  a  suitable 
length  to  be  set  in  sympathetic  vibration  by  certain  of  the 
tones  of  which  the  sound  of  the  thoracic  wall  is  composed  ; 
so  that  the  quality  and  general  pitch  of  the  intrathoracic 
note  does  to  a  certain  extent  depend  upon  the  vibrations 
of  the  chest  w^all.  The  slight  difference  in  pitch  of  the  per- 
cussion sound  during  expiration  and  inspiration  is  thus  to 
be  explained.  When  the  chest  is  in  the  condition  of  full 
inspiration  its  walls  are  tenser  than  during  expiration,  and, 
therefore,  give  a  higher  pitched  note  when  percussed, 
which  note  is  reproduced  and  strengthened  by  the  reso- 
nance of  the  intrathoracic  air  columns,  and  thus  raises  the 
general  pitch  of  the  percussion  sound.* 

3.  Quality. — The  quality  of  a  musical  note  depends  upon 
the  number  and  character  of  its  upper  partial  tones. 
Enough  has  been  said  in  the  last  pages  to  explain  how  this 
applies  to  the  compound  percussion  sounds;  and  the  vari- 
ous well-marked  qualities  which  are  to  be  met  with  clini- 
cally will  be  best  discussed  and  explained  in  the  next 
chapter  when  we  come  to  deal  with  the  practical  aspects  of 
percussion. 

*The  pitch,  then,  of  the  percussion  sound  at  any  given  point  depends 
upon  the  length  of  the  air  columns  which  are  set  in  vibration,  whether 
that  vibration  be  produced  by  direct  impulse  or  by  sympathetic  reso- 
nance; and  the  general  pitch  of  the  compound  percussion  sound  depends 
upon  whether  the  high  or  low-pitched  notes  are  of  larger  number  or 
greater  intensity.  But,  as  I  have  already  said,  the  length  of  some  at 
least  of  these  columns  is  determined  by  limiting  pulmonic  septa.  If  the 
lung  tissue  become  relaxed,  these  septa  no  longer  limit  the  length  of  the 
air  columns,  which  then  extend  back  to  the  opposite  wall  of  the  chest, 
and  consequently  give  a  lower  pitched  note.  Thus,  as  a  whole,  the  per- 
cussion sound  depends  for  its  pitch  upon  three  factors — (i)  the  tenseness 
of  the  chest  wall;  (2)  the  tenseness  of  the  lung  tissue;  (3)  the  length  of 
the  underlying  air  columns. 


152  MEDICAL  DIAGNOSIS. 

CHAPTER  XVIII. 

Respiratory  System — {continued). 

PERCUSSION    OF    THE   CHEST. 

In  the  preceding  chapter  I  have  attempted  to  explain  the 
theory  on  which  the  practice  of  percussion  rests.  It  is  now 
necessary  to  consider  it  in  its  clinical  and  practical  aspects. 
And  first,  of  the 

Methods  of  Percussion. — There  are  two  varieties  of  per- 
cussion, the  immediate  and  the  mediate. 

Immediate  percussion,  or  that  in  which  the  chest  wall  is 
struck  directly  with  the  finger,  was  the  method  originally 
employed.  It  is  now  almost  completely  discarded,  the  only 
exception  being  the  percussion  of  the  clavicles,  which  may 
with  advantage  be  struck  with  the  pulp  of  the  forefinger 
before  the  percussion  of  the  chest  generally  is  commenced. 

Mediate  percussion,  or  that  variety  in  which  the  finger  or 
pleximeter  is  laid  upon  the  chest  wall  and  receives  the 
stroke,  is  now  almost  universally  employed. 

As  a  general  rule,  it  is  probably  best  to  use  one  or  more 
of  the  fingers  of  the  right  hand  to  give  the  stroke,  and  to 
employ  the  fore  or  middle  finger  of  the  left  hand  as  a  plexi- 
meter, applying  its  palmar  surface  firmly  to  that  portion  of 
the  chest  wall  which  we  wish  to  percuss.  For  the  right 
hand  a  percussion  hammer  maybe  substituted,  and  for  a 
pleximeter  we  may  employ  an  ivory  or  vulcanite  plate  of 
any  of  the  numerous  forms  which  are  to  be  found  in  the 
shops  of  surgical  instrument  makers. 

Whether  the  stroke  be  delivered  by  means  of  the  bent 
finger  or  the  hammer,  it  must  be  given  from  the  wrist  alone, 
and  not  from  the  shoulder  or  elbow,  and  the  fingers  or  ham- 
mer must  be  raised  from  the  pleximeter  the  moment  the 
blow  has  been  given,  so  as  to  allow  of  the  free  vibration  of 
the  chest.  Skilful  percussion  with  the  fingers  is  very  diffi- 
cult to  acquire,  and  requires  long  practice;  but  all  students 
should  learn  it,  for  although  hammer  percussion  is  much 
easier,  the  physician  may  often  be  in  circumstances  when 
he  is  compelled  to  percuss  without  the  aid  of  that  instru- 
ment.    Finger  percussion  is  also  much  better  suited  to  give 


RESPIRATORY    SYSTEM.  1 53 

the  feeling  of  resistance  which,  as  will  be  presently  shown, 
is  often  of  considerable  importance. 

The  patient,  if  a  male,  ought  to  be  stripped  to  the  waist, 
and  if  a  female,  only  one  thin  and  soft  garment  ought  to  be 
allowed  to  interpose  between  the  chest  and  the  finger  or 
pleximeter. 

It  is  of  great  importance  that  the  chest  should  be  per- 
cussed symmetrically,  corresponding  points  on  both  sides 
being  compared  with  one  another,  and  it  is  necessary  to 
see  that  the  patient  assumes  no  position  of  head,  limbs,  or 
trunk  which  will  produce  unequal  muscular  tension  on 
either  side. 

As  a  rule,  percussion  need  not  be  very  forcible,  though 
when  the  chest  walls  are  thickened  from  the  deposition 
of  fat,  or  are  dropsical,  a  strong  blow  may  be  necessary  in 
order  to  produce  a  sufficiently  audible  note. 

The  Thoracic  Percussion  Note. — In  the  preceding  chapter 
I  have  indicated  the  theoretical  basis  on  which  I  believe 
the  practice  of  percussion  may  safely  be  held  to  rest;  but 
whatever  their  theoretical  beliefs,  most  physicians  will 
agree  that  the  percussion  sound  depends  mainly  upon  three 
factors — viz.,  (i)  the  thickness  and  tension  of  the  chest 
wall,  (2)  the  tension  of  the  pulmonic  tissue,  and  (3)  the 
amount  and  disposition  of  the  underlying  air;  and  that  it  is 
to  physical  changes  in  these  three  factors  that  we  must 
look  for  the  cause  of  variations  in  the  percussion  note. 

In  the  following  pages  we  shall  consider,  firstly,  the 
changes  in  the  percussion  note  which  occur  as  regards  (a.) 
intensity,  {^.)  pitch,  and  (c.)  quality  (such  as  the  tympan- 
itic note,  cracked-pot  sounds,  etc.);  secondly,  the  feeling  of 
resistance  during  percussion;  thirdly,  the  topographical 
percussion  of  the  lungs;  and  fourthly,  the  subject  of  pho- 
nometry. 

The  Intensity  of  the  Percussion  Sound. — As  has  been  already 
said,  the  intensity  of  a  simple  pendular  tone  depends  upon 
the  amplitude  of  its  vibrations;  but  in  regard  to  the  com- 
pound percussion  sound,  account  must  also  be  taken  of  the 
number  of  air  columns  which  are  thrown  into  vibration, 
and  this  depends  upon  the  force  of  the  stroke,  upon  the 
condition  of  the  chest  walls,  and  upon  the  volume  of  under- 
lying air.  Remembering  that  wiien  two  parts  of  the  chest 
are  being  compared  the  force  of  the  stroke  must  in  each 


154  MEDICAL  DIAGNOSIS. 

case  be  equal,  we  may  limit  our  attention  to  the  two  last 
factors. 

1.  The  Condition  of  the  Chest  Wall. — When  the  thoracic 
wall  is  thickened  b}'^  the  deposition  of  fat,  or  by  the  trans- 
udation of  serum  into  its  interstices,  the  subjacent  air  is 
thrown  with  greater  difficulty  into  vibration  by  the  percus- 
sion stroke,  and  the  resulting  sound  is  deadened  in  passing 
through  the  thickened  chest  wall  to  reach  the  ear  of  the 
physician.  The  same  diminution  of  the  intensity  of  the 
sound  occurs  in  health  over  those  portions  of  the  chest 
which  are  covered  with  thick  muscle — for  example,  the 
scapular  regions,  and  over  the  pectoralis  major;  and  it 
must  be  borne  in  mind  that  in  laborers  in  whom,  from  their 
occupation,  the  right  pectoralis  is  considerably  more  devel- 
oped than  the  left,  the  percussion  note  is  less  intense  on 
the  right  side  over  that  muscle  than  at  a  corresponding 
point  on  the  left.  Pleural  effusions,  also,  have  the  same 
effect  on  the  intensity  of  the  note,  as  the  layer  of  fluid  pre- 
vents the  free  transmission  of  the  percussion  stroke.  Such 
collections  of  fluid  have,  of  course,  a  further  influence  on 
the  note  from  the  compression  of  the  lung  tissue  which 
they  occasion.  The  thickening  of  the  pleurae,  which  re- 
mains after  an  attack  of  pleurisy,  tends  to  diminish  the 
intensity  of  the  percussion  note,  partly  owing  to  the  in- 
creased thickness  of  the  chest  wall  thereby  produced,  but 
also,  I  think,  from  the  manner  in  which  the  strong  adhe- 
sions formed  tend  to  contract,  and  so  bind  together  the 
chest  wall  as  seriously  to-interfere  with  its  free  vibration. 

2.  The  Amount  of  Air  contained  in  the  Chest. — The  intensity 
of  the  chest  note  is  diminished  whenever,  from  any  cause, 
there  is  a  serious  diminution  of  the  air  contained  in  the 
chest.  This  may  result  either  from  compression  of  the 
lung  tissue,  so  as  to  expel  the  air,  such  as  takes  place  in 
cases  of  pleural  effusion  and  of  tumors  pressing  upon  the 
lung,  or  from  infiltration  into  the  alveoli,  such  as  occurs  in 
pulmonary  oedema,  in  the  exudative  stage  of  acute  pneu- 
monia, and  in  all  the  forms  of  chronic  phthisis. 

An  increase  in  the  intensity  of  the  percussion  sound  is  met 
with  (i)  where  the  chest  walls  are  thin,  in  the  young,  the 
old,  and  in  emaciated  subjects;  and  (2)  where  the  volume 
of  air  is  increased,  as  is  seen  when  the  percussion  note  of 
full  inspiration  is  compared  with  that  of  expiration;  and 
further,  in  cases  of  emphysema,  where  the  absolute  volume 
of  intrathoracic  air  is  increased,  not  merely  because  many  of 


RESPIRATORY   SYSTEM.  1 55 

the  pulmonary  septa  have  disappeared  and  their  place  has 
been  taken  by  air,  but  also  on  account  of  the  permanent  po- 
sition of  the  thorax  in  the  condition  of  full  inspiration. 

The  Pitch  of  the  Percussion  Sound. — The  pitch  of  a  note 
depends  upon  the  rapidity  of  the  vibrations  of  which  it  is 
composed,  and  I  have  explained  in  the  previous  chapter 
how  the  term  pitch  may  be  more  or  less  correctly  applied 
to  such  a  compound  sound  as  that  of  percussion.  The  pitch 
of  the  thoracic  note  depends  upon  three  factors — (i)  the 
tension  of  the  chest  wall,  (2)  the  tension  of  the  lung  tissue, 
and  (3)  the  length  of  the  underlying  air  columns  ;  and  I 
have  already  shown  how  these  three  conditions  tend  to 
modify  the  pitch  of  the  note. 

1.  The  State  of  Tension  of  the  Chest  Wall. — When  a  full  in- 
spiration is  made,  the  tension  of  the  chest  wall  increases, 
and  consequently  the  percussion  note  tends  to  rise  in  pitch, 
although  this  tendency  is  to  a  certain  extent  counteracted 
by  the  increase  of  the  volume  of  air  in  the  lungs  which  then 
takes  place.  As  a  whole,  however,  the  pitch  during  inspi- 
ration is  higher  than  during  expiration.  In  the  same  way, 
in  pulmonary  emphysema  the  percussion  note  is  usually 
raised  in  pitch,  owing  in  great  measure  to  the  increased 
tension  of  the  thorax  ;  and  though  the  intensity  of  the  note 
(as  has  been  already  said)  is  increased  in  these  cases,  I  have 
frequently  seen  emphysema  mistaken  by  the  inexperienced 
for  pulmonary  consolidation,  owing  to  the  heightened  pitch. 

2.  The  State  of  Tension  of  the  Fulmonic  Tissue. — The  in- 
creased tension  of  the  lung  tissue,  during  full  inspiration, 
no  doubt  tends  to  heighten  the  pitch  of  the  percussion  note, 
along  with  the  tension  of  the  chest  wall  above  mentioned. 
The  results  of  relaxation  of  the  lung  tissue  will  be  best  de- 
scribed when  we  come  to  speak  of  the  tympanitic  note. 

3.  The  Length  of  the  tmderlying  Air  Colicmns. — Whenever 
the  air-containing  cavity  lying  under  the  point  of  percus- 
sion becomes  more  or  less  filled  up,  either  as  the  result  of 
effusion  of  fluid  into  the  pleural  cavity,  or  of  effusion  or 
exudation  into  the  alveoli,  such  as  take  place  in  oedema, 
pneumonia,  and  in  the  various  forms  of  phthisis,  the  air 
columns  become  shortened,  and  the  percussion  note  rises  in 
pitch.  The  same  result  follows  where,  from  the  deposition 
of  new  formations  in  the  lung  tissue,  the  air  columns  be- 
come broken  up  in  their  length.  Within  these  limits  fall  the 
greater  number  of  pathological  conditions  which  are  met 


156  MEDICAL  DIAGNOSIS. 

with  in  connection  with  the  lungs.  In  each  special  case  it 
is  not  difficult  to  see  how  the  note  becomes  modified  as  re- 
gards its  pitch. 

In  like  manner  is  to  be  explained  the  change  of  note 
which  occurs  when  we  pass  from  the  lungs  to  such  solid 
organs  as  the  liver  and  heart,  and  which  enables  us  to  map 
out  their  outlines  in  the  manner  already  described.  Take 
the  liver  for  an  example  :  As  we  percuss  downwards  in  the 
mamillary  line,  we  reach  the  upper  margin  of  relative  liver 
dulness — that  point,  namely,  where  the  sound  first  becomes 
modified.  It  is  here  that  the  liver,  lying  in  the  hollow  of 
the  diaphragm,  first  begins  to  encroach  upon  the  air  space, 
filling  it  up  from  behind,  and  thereby  shortening  the  air 
columns,  and  diminishing  the  volume  of  underlying  air. 
The  intensity  of  the  note  is  thereby  diminished,  and  its 
pitch  rises,  and  these  changes  in  the  percussion  note  be- 
come more  and  more  marked  until  we  come  to  the  upper 
limit  of  absolute  liver  dulness,  where  no  lung  tissue  inter- 
poses itself  between  the  liver  and  the  chest  w^all,  and  the 
note,  therefore,  becomes  absolutely  dull.  In  the  same  way, 
the  topographical  percussion  of  other  solid  organs  is  to  be 
explained. 

Passing  now  to  the  consideration  of  certain  changes  in 
the  quality  of  the  percussion  note,  we  come  first,  and  most 
importantly,  to 

The  Tympanitic  Percussion  Note. — This  variety  of  chest 
note  differs  from  that  of  health  in  that  it  approaches  much 
more  nearly  to  a  pure  musical  tone — that  is,  its  vibrations 
become  much  more  regular.  The  great  regularity  of  these 
vibrations  Gerhard  has  shown  by  means  of  Konig's  sensi- 
tive flame  reflected  in  a  rotating  mirror.  This  variety  of 
percussion  note  is  found  in  perfection  over  the  stomach 
when  that  viscus  is  moderately  distended  with  air.  If  the 
stomach  be  removed  from  the  body,  both  orifices  ligatured, 
and  then  moderately  distended  with  air,  it  will  be  found  to 
afford  a  tympanitic  note  on  percussion;  but  if  the  disten- 
sion be  continued,  a  point  will  soon  be  reached  when  the 
note  loses  that  peculiar  quality  and  becomes  muffled.  The 
reason  of  this  is  not  far  to  seek.  In  the  case  of  moderate 
distension,  the  gastric  wall  is  not  sufficiently  tense  to  pass 
into  vibration,  and  thus  the  sound  results  simply  from  the 
vibrations  produced    in  the  contained  air;   but  when  the 


RESPIRATORY   SYSTEM.  1 57 

walls  become  tense  from  over-distension  they  also  vibrate, 
and  the  tones  so  produced  do  not  harmonize  with  those  of 
the  vibrating  air,  so  that  the  combined  sound  is  irregular 
in  its  vibrations,  and  therefore  no  longer  tympanitic. 

Similarly,  if  a  lung  be  removed  from  the  body  and  al- 
lowed to  collapse,  it  will,  when  percussed,  give  a  tympanitic 
note,  which  "disappears  when  the  lung  is  again  distended 
with  air  to  a  point  corresponding  to  the  normal  condition. 
The  air  in  the  collapsed  lung  vibrates  as  a  whole,  and  the 
lung  tissue  is  not  sufficiently  tense  to  admit  either  of  its 
passing  into  vibration,  or  of  the  stronger  septa  breaking  up 
the  air  columns  so  as  to  render  the  combined  note  irregular 
and  non-tympanitic,  as  is  the  case  when  the  lung  is  in  a 
state  of  normal  distension.  It  is  to  be  noted  that  the  pitch 
of  the  tympanitic  note  (which  is  very  readily  made  out) 
gives  a  trustworthy  indication  of  the  size  of  the  air  cavity, 
and  this  is  very  important  as  a  means  of  distinguishing  the 
note  of  the  stomach  from  that  of  the  neighboring  intes- 
tine. 

Further  illustrations  of  the  tympanitic  note  in  health  are 
to  be  found  when  percussion  is  made  on  the  cheek  when 
the  mouth  is  moderately  distended  with  air,  or  over  the 
trachea.  The  latter  example  is  of  especial  value  in  that  it 
shows  another  property  of  the  percussion  note — viz.,  that 
when  the  orifice  of  the  cavity  is  narrowed  or  closed,  the 
pitch  of  the  note  falls.  If  the  trachea  be  percussed,  first 
with  the  mouth  open,  and  then  with  it  shut,  this  lowering 
of  the  pitch  will  be  readily  detected,  and  it  will  be  still  more 
obvious  if  the  nostrils  be  at  the  same  time  compressed. 

From  what  has  just  been  said,  it  will  be  seen  that  the 
tympanitic  note  may  occur  in  the  chest  under  the  following 
pathological  conditions: 

1.  Relaxation  of  lung  tissue. 

2.  The  presence  of  underlying  air  cavities. 

3.  Pulmonary  consolidation,  allowing  the  broncho-tra- 
cheal  air  column  to  be  set  in  vibration. 

I.  Relaxation  of  Ltmg  Tissue. — Just  as  when  the  lung  is  re- 
moved from  the  body,  and  allowed  to  collapse,  it  gives  a 
tympanitic  note,  so  when  a  similar  retraction  and  relaxa- 
tion of  the  pulmonic  tissue  takes  place  within  the  thorax, 
this  variety  of  percussion  note  may  be  heard.  This  is  best 
marked  in  cases  of  pleuritic  effusion,  which,  gravitating  to 
the  lower  portion  of  the  cavity,  floats  up  the  lung  and 
causes  retraction  of  the  upper  portions.    When  the  effusion 


158  MEDICAL  DIAGNOSIS. 

is  small  in  amount  this  tympanitic  note  can  only  be  detect-, 
ed  over  that  portion  of  lung  which  lies  immediately  above 
the  upper  limit  of  the  fluid,  but  when  the  effusion  is  con- 
siderable the  whole  upper  lobe  may  be  tympanitic  on  per- 
cussion.* Similarly,  effusion  into  the  alveoli  (in  pneumonia 
or  oedema)  may  produce  a  like  result.  In  the  first  stage  of 
pneumonia  the  change  in  the  note  seems  to  be'  produced  by 
relaxation,  occasioned  by  the  inflammatory  congestion  of 
the  lung  issue.  Phthisical  consolidation  of  the  apices  may 
also  be  accompanied  with  an  obscurely  tympanitic  note  over 
the  neighboring  portions  of  lung. 

It  is  particularly  to  be  observed  that  the  pitch  of  the 
tympanitic  note  which  occurs  under  the  above  conditions 
is  not  altered  by  shutting  and  opening  the  mouth. 

2.  The  Presence  of  underlying  Air  Cavities. — When  the 
pleural  cavity  becomes  filled  with  air  (pneumothorax)  a 
typically  tympanitic  note  results  from  percussion,  provided 
that  the  distension  be  not  too  great.  Its  pitch  is  not  altered 
by  opening  and  closing  the  mouth.  When  the  cavity  con- 
tains in  addition  serum  or  pus  (hydro-  or  pyo-pneumotho- 
rax)  the  note  changes  in  pitch  with  the  position  of  the  pa- 
tient, the  fluid  gravitating  to  the  most  dependent  part  in 
each  instance,  and  so  altering  the  lengths  of  the  air  columns. 

Cavities  in  the  lung  tissue,  when  filled  with  air  of  suffi- 
cient size,  smooth  walled,  and  near  to  the  thoracic  wall, 
also  give  a  tympanitic  note,  and  as  they  communicate  with 
a  bronchus,  the  pitch  of  their  note  varies  when  the  mouth 
is  opened  and  closed.  The  position  of  the  long  axis  of  the 
cavity  may  also  be  ascertained,  if  it  contain  fluid  as  well  as 
air,  for  the  movements  of  the  fluid  occasioned  by  altera- 
tions in  the  position  of  the  patient  cause  changes  in  the 
pitch  of  the  note,  just  as  in  hydro-pneumothorax  (Ger- 
hardt).  This  change  is  extremely  characteristic  of  cavities 
in  the  lung. 

3.  Pulmonary  Consolidation,  allowing  the  Broncho- Tracheal 
Air  Column  to  be  set  in  Vibration, — I  have  already  alluded  to 
the  tracheal  sound,  which  is  characteristically  tympanitic. 
In  health,  however,  it  is  not  possible  to  set  in  vibration  the 
air  column  in  the  bronchi  and  trachea  by  percussing  over 
the  chest.  If,  however,  the  lung  tissue  be  consolidated,  the 
impulse  of  the  percussion  stroke  may  be  transmitted  to  the 

*  When  the  effusion  is  excessive  the  lung  tissue  becomes  compressed, 
and  the  tympanitic  quality  of  the  note  is  consequently  lost. 


RESPIRATORY   SYSTEM.  1 59 

bronchi,  and  in  this  way  the  tympanitic  tracheal  note  of 
Williams  may  be  produced.  This  note  is  almost  always 
found  on  the  left  side — rarely  on  the  right,  and  it  is  charac- 
teristic of  it  that  the  pitch  is  altered  by  opening  and  closing 
the  mouth,  but  7iot  by  changes  in  the  position  of  the  patient. 
Another  note  peculiar  in  quality,  which  must  be  men- 
tioned, is  the 

Cracked-Pot  Sound  {Bnnt  de  Pot Fel^). — The  peculiar  qual- 
ity of  this  sound  is  caused  by  the  sudden  expulsion  of  air 
from  a  cavity  through  a  small  opening  in  its  walls,  and  it 
is  well  heard  when  the  hands  are  pressed  together  and 
struck  upon  the  knee,  in  a  manner  well  known  to  school- 
boys, so  as  to  produce  a  noise  closely  resembling  the  rat- 
tling of  coin.  It  derives  the  name  (which  Laennec  first 
gave  it)  from  the  resemblance  to  the  sound  produced  by 
striking  a  cracked  jar. 

The  cracked-pot  sound  occurs  under  the  following  con- 
ditions: 

1.  In  Health. — In  children,  when  the  glottis  is  narrowed, 
either  during  a  fit  of  crying  or  when  a  sustained  high- 
pitched  note  is  being  sung,  percussion  of  the  chest  gives 
this  variety  of  sound,  the  air  being  suddenly  forced  from 
the  lung  through  the  narrow  glottis.* 

2.  I?i  Cases  of  Relaxation  of  Lung  Tissue,  which  I  have  al- 
ready described  as  favoring  the  production  of  tympanitic 
percussion,  the  cracked-pot  sound  may  sometimes  be  heard. 

3.  In  Cases  of  Thoracic  Fisiulce  and  pneumothorax,  when 
the  percussion  stroke  expels  air  through  the  fistula  with  a 
hissing  sound. 

4.  In  Cases  of  Pulmonary  Excavation. — This  is  by  far  the 
most  frequent  cause  of  the  cracked-pot  sound,  so  much  so 
that  when  consolidation  of  the  lung  tissue  exists,  the 
cracked-pot  sound  may  be  taken  as  strong  evidence  of  the 
presence  of  a  cavity. 

The  last  change  in  quality  which  we  shall  here  consider 
is  that  which  is  known  as 


*  Also  in  adults,  when  the  chest  is  very  hairy,  and  a  pleximeter  is  be- 
ing used,  the  cracked-pot  sound  is  apt  to  be  produced.  Owing  to  the 
instrument  not  being  closely  applied  to  the  chest  wall,  a  layer  of  air  in- 
tervenes and  a  portion  is  forcibly  expelled  by  the  percussion  stroke,  pro- 
ducing the  sound  in  question.  Moistening  the  hair  does  away  with  this 
difficulty. 


l6o  MEDICAL  DIAGNOSIS. 

Amphoric  Resonance. — This  sound  is  similar  to  one  pro- 
duced by  striking  on  the  side  of  an  empty  jar  or  cask,  and 
it  owes  its  peculiar  metallic  quality  to  the  high-pitched  up- 
per partial  tones  which  it  possesses,  and  which  are  caused 
by  the  reflection  of  the  waves  of  sound  from  side  to  side 
of  the  closed  cavity.  These  upper  partial  tones  die  away 
slowly. 

When  speaking  of  the  tympanitic  percussion  sound,  it 
was  pointed  out  that  when  the  stomach  is  over-distended 
with  air  that  quality  is  lost,  the  note  becoming  hard  and 
metallic.  Amphoric  resonance  is  then  formed,  the  sound 
waves  being  again  and  again  reflected  from  the  tense  walls 
of  the  viscus. 

The  conditions  necessary  for  the  production  of  amphoric 
resonance  are  that  the  air-containing  cavity  should  be  of 
considerable  size  and  superficial,  that  its  walls  should  be 
smooth  and  resistant,  and  that  it  should  either  be  completely 
closed  or  should  only  communicate  with  the  external  air 
by  means  of  a  small  opening. 

As  in  the  tympanitic  note,  so  also  in  the  amphoric  sound, 
the  pitch  of  the  prime  tone  enables  us  roughly  to  estimate 
the  size  of  the  cavity  in  question. 

In  thoracic  percussion  this  amphoric  echo  is  met  with  in 
two  conditions — over  pulmonary  cavities,  and  in  pneumo- 
thorax. In  both  these  cases  it  is  best  to  combine  ausculta- 
tion with  percussion,  the  physician  listening  with  a  stetho- 
scope in  the  neighborhood  of  the  cavity,  while  an  assistant 
percusses.  For  percussion  it  is  best  to  use  a  pleximeter, 
and  to  strike  it  with  some  hard  substance  such  as  a  coin, 
as  the  metallic  note  thus  produced  brings  out  by  sympa- 
thetic resonance  the  high-pitched  upper  partials  of  the 
cavity. 

Feeling  of  Resistance  During  Percussion. — The  sound  which 
the  percussion  of  the  chest  affords  is  not  the  only  sensation 
which  is  perceived  by  the  physician  in  consequence  of  the 
stroke.  There  is  further  a  sense  of  the  degree  to  which  the 
chest  walls  yield  to  the  force  of  the  blow. 

This  feeling  of  resistance  may  be  dependent  solely  upon 
such  changes  in  the  chest  wall  as  tend  to  increase  its  solid- 
ity (such  as  deposit  of  fat,  thickening  of  the  ribs,  etc.),  but 
if  we  expect  these,  it  gives  a  trustworthy  and  sometimes 
exceedingly  valuable  indication  of  the  comparative  solidity 
of  underlying  organs.    Whenever  the  lung  becomes  airless, 


RESPIRATORY   SYSTEM.  l6l 

whether  from  exudation  or  compression,  the  resistance  is 
increased;  and  still  more  is  this  the  case  when  effusion  of 
fluid  has  taken  place  into  the  pleura,  and  most  of  all  over 
intrathoracic  tumors. 

Diminution  of  resistance  is  met  with  in  cases  of  pulmo- 
nary emphysema,  when  well  marked,  and  in  pneumothorax. 

Topographical  and  Regional  Percussion. — The  limits  with- 
in which  the  pulmonary  percussion  note  is  heard  are  of 
importance,  not  only  in  determining  the  outline  of  neigh- 
boring solid  organs,  but  as  a  guide  to  the  physical  condition 
of  the  lungs  themselves. 

The  Apices. — The  upper  limit  of  the  lung  note  corresponds 
to  a  line  which,  following  at  first  the  clavicular  portion  of 
the  sternomastoid  muscle,  curves  over  to  meet  the  anterior 
margin  of  the  trapezius,  and  then  passes  downwards  to  the 
seventh  cervical  vertebra.  This  line  rises  on  each  side  to  a 
point  about  \\  to  2  inches  (3  to  5  centimetres,  according 
to  Leitz)  above  the  clavicle,  being  perhaps  a  trifle  higher 
on  the  right  side.  In  percussing  the  apices,  care  must  be 
taken  that  the  patient's  head  is  not  turned  to  either  side, 
and  that  the  direction  as  well  as  the  force  of  the  stroke  is 
the  same  on  each  side.  The  shrinking  of  the  apices,  both 
vertically  and  transversely,  is  one  of  the  first  physical  signs 
of  incipient  phthisis,  and  is  therefore  of  considerable  im- 
portance. In  pulmonary  emphysema,  the  limits  above 
given  may  be  overstepped  to  a  considerable  extent. 

The  a?iterior  margins  approach  each  other  at  the  level  of 
the  second  cartilage,  being  separated  only  by  the  anterior 
mediastinum,  and  continue  downwards  parallel  to  each  other 
as  far  as  the  fourth  rib,  where  the  margin  of  the  left  lung 
curves  outwards  to  follow  the  line  of  the  absolute  cardiac 
dulness,  as  already  described;  while  that  of  the  right 
lung  continues  vertically  downwards  as  far  as  the  sixth 
cartilage,  where  it  joins  the  inferior  margin. 

The  inferior  margins  are  much  affected  by  respiration. 
Their  position  during  quiet  respiration  may  be  taken  to  be 
as  follows: 

The  right  lung — 

At  sternal  border,      ,         ,         ,     6th  rib. 

Parasternal  line,         .         ,         .     6th  rib. 

Mammillary  line.        .         .         .7th  rib,  upper  border. 

Axillary  line,      ....     8th  rib. 

Scapular  line,     ....     9th  rib. 


l62  MEDICAL  DIAGNOSIS. 

At  vertebral  column,  .         ,         .  nth  rib. 
The  left  lung — 

Axillary  line,      ....     8th  rib. 

Scapular  line.     ....     9th  rib. 

At  vertebral  column,  .  .  .  nth  rib. 
With  forced  respiration  the  inferior  edges  of  the  lungs 
rise  and  fall  very  considerably — to  such  an  extent,  indeed, 
that  in  the  axillary  line  there  may  be  a  difference  of  over  3 
inches  befween  full  expiration  and  full  inspiration.  In 
cases  of  emphysema,  not  only  are  the  lower  borders  much 
depressed,  but  their  movement  during  respiration  is  greatly 
interfered  with. 

The  influence  of  emphysema,  and  other  pathological 
conditions  on  the  anterior  borders  of  the  lungs,  has  been 
already  alluded  to  in  connection  with  the  percussion  of  the 
heart. 

Regional  Percussion. — The  difference  of  the  percussion 
sound  at  different  parts  of  the  healthy  lung  depends  upon 
the  condition  of  the  chest  wall,  and  upon  the  number  and 
disposition  of  the  air  columns  which  radiate  from  the  point 
struck. 

Anteriorly. — The  sound  over  the  apices  above  the  clavicles 
is  clear,  but  not  great  in  intensity.  Below  the  clavicles  the 
note  falls  somewhat  in  pitch,  and  grows  in  intensity  until 
we  come  to  the  relative  dulness  of  the  heart  on  the  left  side 
(lower  margin  of  third  rib)  and  of  the  liver  on  the  right 
(fourth  inter-space,  or  fifth  rib),  when  in  both  cases  the 
sound  rises  in  pitch  and  loses  intensity,  and  does  so 
more  and  more  until  the  limit  of  absolute  dulness  of  each 
solid  organ  is  reached.  The  right  lung  is  usually  slightly 
duller  than  the  left,  owing  to  the  greater  development  of 
muscle  on  the  right  side.  Over  the  sternum  the  sound  is 
clear,  deep,  and  resounding,  owing  in  part  to  the  vibrations 
of  that  bone,  but  chiefly  to  the  fact  that  the  air  in  both 
lungs  is  set  in  vibration. 

Posteriorly. — In  percussing  the  thorax  posteriorly,  the 
patient  should  be  made  to  cross  his  arms  in  front  and  bend 
forward.  The  note  over  the  scapulae  is  less  clear  than  that 
at  the  lower  portions  of  the  back.  The  lung  note  can  be 
heard  as  low  down  as  the  tenth  or  eleventh  rib. 

Laterally. — In  the  axillary  regions  the  pulmonary  note  is 
intense  and  clear  on  both  sides  until  the  dulness  of  the  liver 
is  reached  on  the  right  side,  and  that  of  the  spleen  on  the 
left. 


RESPIRATORV   SYSTEM.  163 

CHAPTER  XIX. 
Respiratory  System — {continued), 

AUSCULTATION. 

The  auscultation  of  the  lungs  may  be  performed  with 
the  aid  of  a  stethoscope,  or  more  simply  by  applying  the 
ear  to  the  thoracic  wall.  For  obvious  reasons,  the  former 
method  is  the  pleasanter  both  to  patient  and  to  physician, 
and  it  possesses  this  further  advantage  that,  by  means  of 
the  stethoscope,  any  abnormal  auscultatory  phenomenon 
can  be  more  distinctly  localized  than  is  possible  if  the  im- 
mediate method  be  employed.  The  form  of  instrument  is 
of  comparatively  little  importance,  provided  that  it  fits  the 
ear  of  the  physician.  The  simple  wooden  stethoscope  an- 
swers admirably  for  all  ordinary  cases,  although  sometimes 
the  double  instrument  of  Alison  may  be  made  use  of  with 
advantage. 

The  position  of  the  patient  is  of  considerable  importance. 
Where  there  is  a  choice,  probably  the  sitting  posture  is  the 
most  convenient,  but  whatever  attitude  be  adopted  it  must 
be  unconstrained.  Of  at  least  equal  moment  is  the  posture 
of  the  physician,  which  should  be  easy  and  comfortable. 
The  chest  of  the  patient  should,  if  possible,  be  fully  uncov- 
ered; but  failing  this,  the  intervening  clothes  must  be  thin, 
and  all  friction  between  them  and  the  stethoscope  sedu- 
lously avoided.  The  instrument  should  be  firmly  and  ac- 
curately applied  to  the  chest,  and  not  till  then  should  the 
physician  apply  his  ear  to  the  upper  end,  always  remem- 
bering that  the  ear  must  be  moved  so  as  to  suit  the  stetho- 
scope, and  not  the  stethoscope  to  suit  the  ear.  Attending 
to  these  precautions,  the  whole  chest  must  be  carefully 
examined,  corresponding  points  on  the  two  sides  being 
compared  in  the  same  manner  as  in  percussion. 

On  auscultating  the  chest  there  is  to  be  heard  at  most 
points  a  gentle  ''breezy"  sound — the  vesicular  murmur — 
which  resembles  the  sighing  of  wind  among  leaves,  and 
the  special  character  of  which  is  readily  learned  by  a  little 
practice.  It  consists  of  two  murmurs,  the  one  correspond- 
ing to  inspiration  and  the  other  to  expiration,  of  which  the 
first  is  about  three  times  as  long  as  the  second,  and  is  softer 


164  MEDICAL  DIAGNOSIS. 

and  higher  in  pitch.*  Not  only  do  pathological  changes 
in  the  lungs  alter  the  ordinary  respiratory  murmur,  but 
they  often  produce  totally  different  sounds,  to  which  in 
turn  our  attention  must  be  directed.  In  ordinary  clinical 
examination,  then,  the  main  points  to  be  attended  to  in 
regard  to  auscultation  are — 

1.  The  relative  duration  of  the  expiratory  and  inspiratory 

murmurs. 

2.  The  character  or  quality  of  the  breathing  sounds. 

3.  The  presence  or  absence  of   adventitious  sounds  of 

various  kinds. 

4.  The  character  of  the  vocal  resonance  (auscultation  of 

the  voice). 

Vesicular  Breathing. — In  speaking  of  murmurs  arising  in 
the  blood  current,  I  have  already  pointed  out  that  when  a 
fluid  streaming  through  a  tube  passes  from  a  narrower  into 
a  wider  portion,  vibrations  arise  in  the  fluid  owing  to  the 
friction  of  the  molecules  upon  one  another,  which,  if  suffi- 
ciently rapid,  give  rise  to  an  audible  murmur.  This  is 
equally  true  with  regard  to  gases.  Now,  in  the  air 
passages  there  are  two  points  at  which  such  an  altera- 
tion in  calibre  is  to  be  found — viz.,  at  the  glottis  and  at 
the  point  where  the  bronchioles  enter  the  alveoli.  The 
rush  of  air  through  the  narrow  glottis  sets  in  vibration  the 
air  column  contained  in  the  trachea  and  bronchi,  and  a 
blowing  murmur  results — the  tracheal  or  bronchial  ipur- 
mur — which  will  be  described  more  fully  hereafter;  and  in 
a  similar  manner  a  murmur  arises  as  the  air  streams  into 
the  air  cells.  To  a  combination  of  these  two  murmurs,  in 
which  the  latter  predominates,  it  appears  most  reasonable 
to  ascribe  the  formation  of  the  normal  vesicular  breath 
sound. f  Whatever  be  its  origin,  however,  it  may  be  safely 
held  that,  when  vesicular  breathing  is  heard,  the  pulmonary 
alveoli  are  fulfilling  their  function,  and  when  it  is  absent, 
that  that  function    is  in  more  or  less  complete  abeyance. 

Vesicular  breathing  is  to  be  heard  more  or  less   clearly 

*  The  expiratory  murmur  is,  however,  not  unfrequently  inaudible  in 
healthy  persons. 

•)•  Baas,  Gerhardt,  and  others,  however,  hold  that  the  vesicular  as  well 
as  the  bronchial  murmur  arises  solely  at  the  glottis,  and  that  the  sound 
is  in  the  former  case  modified  by  transmission  through  the  lung  tissue. 
The  theory  is  attractive,  but  the  proof  offered  seems  inadequate,  more 
especially  as  clinical  facts  point  in  the  other  direction. 


RESPIRATORY   SYSTEM.  165 

over  the  whole  pulmonary  surface,  but  it  varies  in  distinct- 
ness at  different  parts  according  to  the  thickness  of  the 
chest-wall  and  the  volume  of  lung  tissue  underlying  the 
stethoscope.  From  various  causes  vesicular  breathing  may 
be  absent.  Thus  it  may  be  replaced  by  bronchial  breath- 
ing, or  it  may  be  inaudible,  owing  to  the  loudness  of 
superadded  sounds,  or  to  the  interposition  of  a  tumor  or  of 
fluid  between  lung  and  chest-wall;  or,  finally,  it  may  be 
absent  owing  to  obstruction  of  a  bronchus  or  to  collapse 
of  lung  tissue. 

The  common  modifications  of  vesicular  breathing  are  as 
follows: 

1.  Harsh  or  puerile. 

2.  Jerk3\ 

3.  Prolongation  of  the  expiratory  murmur, 

4.  Systolic  vesicular  breathing. 

(i.)  Harsh  Vesiadar  Breathing. — In  children  the  normal 
vesicular  breathing  is  clear,  sharp,  and  loud,  and  this  harsh 
or  puerile  breathing  appears  to  depend  in  part  upon  the 
thinness  of  the  chest-walls  and  the  greater  elasticity  of  the 
lung  tissue. 

In  adults  harsh  or  puerile  breathing  usually  indicates  a 
catarrhal  condition  of  the  bronchial  mucous  membrane. 
When  heard  over  the  lung  tissue  generally  it  is  not,  as  a 
rule,  of  so  much  importance  as  when  the  harsh  quality  is 
only  perceptible  at  one  or  both  apices,  which  sign,  when 
persistent,  points  strongly  to  incipient  phthisis. 

(2.)  Jerky  Breathing. — In  nervous  persons,  and  particu- 
larly in  hysterical  women,  the  inspirator}^  vesicular  murmur 
is  very  apt  to  be  broken  into  three  or  four  distinct  parts. 
This  jerky  breathing,  which  is  heard  over  the  whole  lungs, 
disappears  when  the  patient  is  told  to  take  a  deep  inspira- 
tion, and  is  of  no  practical  importance.  But  there  is  an- 
other variety  of  jerky  breathing  which  does  not  so  disap- 
pear, which  is  localized,  and  which  is  met  with  in  incipient 
phthisis.  This  broken  inspiration  is  a  sign  of  considerable 
importance,  and  depends  for  its  production  upon  some  lo- 
cal obstruction  to  the  entrance  of  air  into  the  alveoli. 

(3.)  Vesicular  Breathi7ig  with  Prolonged  Expiratiofi. — It  has 
been  said  that  in  healthy  persons  the  expiratory  murmur 
is  frequently  inaudible.  When  it  is  audible  its  duration  is 
usually  about  one-third  that  of  inspiration.  When  expira- 
tion exceeds  this  length  w^e  may  conclude  that  either  the 
lung  tissue  has  lost  its  elasticity,  or  that   there   is   some 


l66  MEDICAL   DIAGNOSIS. 

obstruction  to  the  escape  of  air.  One  or  other  of  these  two 
conditions  is  met  with  in  almost  every  affection  of  the  lungs, 
so  that  in  pulmonary  disease  a  prolongation  of  the  expira- 
tory murmur  is  almost  universal. 

(4.)  Systolic  Vesicular  Breathing. — Often  during  inspiration 
the  breathing  may  be  heard  to  be  momentarily  strength- 
ened during  the  cardiac  systole.  When  the  heart  contracts, 
the  neighboring  portions  of  lung  expand  more  rapidly  to 
take  the  place  formerly  occupied  by  the  heart  in  diastole, 
and  thus  the  systolic  strengthening  of  the  inspiration  oc- 
curs. Its  presence  has  not  as  yet  been  shown  to  be  of  any 
diagnostic  significance. 

Bronchial  Breathing. — The  second  great  variety  of  respir- 
tory  murmur  is  that  which  is  know  as  laryngeal,  tubular,  or 
bronchial.  It  can  be  heard  in  perfection  when  the  stetho- 
scope is  placed  over  the  larynx  or  trachea.  Its  peculiar 
character  may  be  imitated  by  arranging  the  position  of  the 
mouth  and  tongue  to  utter  the  gutteral  ''Ch,"  and  then 
breathing  quietly  out  and  in.  The  expiratory  portion  of 
the  murmur  is  as  long  or  longer  than  the  inspiratory,  and 
usually  somewhat  lower  in  pitch. 

Bronchial  breathing  cannot  be  heard,  in  health,  over  the 
chest  generally.  Its  area  is  confined  to  the  larynx  and 
trachea  in  the  neck,  and  to  the  interscapular  region  close 
to  the  vertebral  column^  (from  the  seventh  cervical  to  the 
third  or  fourth  dorsal  vertebra),  opposite  to  the  bifurcation 
of  the  trachea,  where,  however,  its  special  character  is  not 
so  well  marked  as  in  the  former  situations. 

Mode  of  production  of  the  Bronchial  Bespiratory  Murmur. — 
The  air  passing  in  and  out  of  the  chest  with  the  movements 
of  respiration  encounters  at  the  glottis  a  considerable  nar- 
rowing of  the  tube  through  which  it  is  flowing,  and  in  con- 
sequence vibrations  arise  in  the  immediate  neighborhood 
of  the  narrow  point,  which  are  of  sufficient  rapidity  to  be 
audible  as  a  murmur.  Underlying  this  vibrating  point, 
however,  there  is  the  air  column  contained  in  the  trachea 
and  bronchi,  which  is  set  in  vibration  by  sympathetic  re- 
sonance, and  thus  the  glottis  murmur  is  augmented  and  re- 
inforced. It  is  in  this  manner,  in  all  probability,  that  the 
bronchial  murmur  in  healthy  persons  is  produced.     It  can 

*  It  is  usually  more  distinct  on  the  right  side  than  on  the  left,  owing 
to  the  greater  calibre  and  more  superficial  position  of  the  right  bronchus. 


RESPIRATORY   SYSTEM.  167 

readily  be  understood  how,  when  the  opening  of  the  glottis 
is  narrowed  by  such  a  pathological  process  as  croup,  the 
murmur  is  louder  and  higher  in  pitch. 

To  the  vibrations  at  the  glottis,  and  those  of  sympathetic 
resonance  in  the  broncho-tracheal  air  column,  other  vibra- 
tions may,  however,  be  added  in  consequence  of  patholo- 
gical changes  in  the  air  passages.  When  the  lumen  of  the 
trachea  is  narrowed,  as  the  result  of  the  pressure  of  a 
tumor,  vibrations  and  a  consequent  murmur  arise  at  the 
stenosed  point,  and  are  reinforced  by  the  underlying  air- 
column  just  as  the  glottis  murmur  is  ;  and  even  when  the 
mucous  membrane  of  the  trachea  and  bronchi  becomes 
swollen  and  roughened  by  catarrhal  processes,  the  charac- 
ter of  the  bronchial  murmur  changes,  and  it  becomes 
harsh — the  result,  no  doubt,  of  local  vibrations. 

The  Bronchial  Murmur  in  Disease. 

As  I  have  already  said,  the  bronchial  murmur  is  only 
audible  in  health  over  the  larynx,  trachea,  and  less  distinct- 
ly between  the  shoulder-blades.  It  cannot  be  heard  over 
the  chest  generally,  partly  because  it  is  overpowered  by 
the  vesicular  murmur,  and  partly  because  inflated  lung 
tissue  is  a  very  bad  conductor  of  sound.  This  murmur  be- 
comes audible,  however,  under  two  varieties  of  pathological 
conditions,  as  follows  : 

(i.)  When  the  lung  tissue  becomes  condeiised — provided  that 
the  condensation  is  extensive,  and  lies  at  or  close  to  the  sur- 
face of  the  lung,  and  contains  besides  a  large  and  unob- 
structed bronchus — the  vesicular  murmur  disappears  over 
the  condensation,  and  the  bronchial  murmur  is  conducted 
to  the  surface  and  becomes  audible.  These  conditions  are 
fulfilled  in  the  case  of  acute  pneumonia  (stage  of  hepatiza- 
tion), and  in  all  the  varieties  of  chronic  phthisis.  Bronchial 
breathing  is  therefore  heard  over  hepatized  lung,  and  wher- 
ever phthisical  consolidation  is  of  sufficient  extent.  It  also 
occurs  when  the  lung  tissue  is  consolidated  as  the  result  of 
compression  and  collapse — as,  for  example,  above  the  level 
of  a  pleuritic  effusion  ;  but  it  is  not  by  any  means  always 
met  with  under  such  conditions,  for  the  pressure  of  the 
effusion  must  be  sufficient  to  cause  collapse  of  the  air-cells, 
and  yet  not  sufficient  to  obliterate  the  bronchi. 

(3.)  In  pulmonary  cavities. — Bronchial  breathing  may  be 
heard  over  vomicae,  provided  that  they  are  superficial,  have 


l68  MEDICAL  DIAGNOSIS. 

smooth  walls,  are  surrounded  by  condensed  tissue,  and 
freely  communicate  by  means  of  a  bronchus  with  the  air  in 
the  trachea.  In  certain  cases  it  may  be  possible  to  judge 
roughly  of  the  size  of  the  cavity  by  the  pitch  of  the  bron- 
chial murmur  heard  over  it,  since  the  air  rushing  into  the 
cavity  excites  sympathetic  resonance  in  it — that  is,  calls 
forth  its  special  tone,'  which  corresponds  to  the  size  of  the 
resonating  cavity,  and  this,  if  loudly  enough  heard,  gives  a 
guide  to  its  size. 

It  is  not,  I  think,  desirable  to  subdivide  bronchial  breath- 
ing into  a  number  of  different  varieties,  as  such  a  course 
only  tends  to  cause  confusion  without  apparently  promoting 
any  useful  purpose.  It  may,  however,  be  well  to  mention 
that  many  writers  recognize  a  modification  of  bronchial  re- 
spiration, which  Laennec  named  "cavernous  breathing,"  in 
which  the  air  appears  to  the  ear  of  the  auscultator  to  pass 
into  a  large  hollow  space.  It  is  not,  nevertheless,  charac- 
teristic of  the  presence  of  a  vomica. 

There  is,  however,  one  special  variety  of  bronchial 
breathing  to  which  attention  must  be  directed,  viz  : 

I  Amphoric  Respiration. 

The  peculiar  character  of  this  variety  of  bronchial  breath- 
ing is  perfectly  reproduced  by  blowing  into  an  empty  jar 
or  bottle,  and  its  mode  of  origin  is  similar  to  that  of  the 
sound  so  obtained.  Amphoric  breathing  occurs  under  two 
pathological  conditions — (i)  pulmonary  excavation,  and 
(2)  pneumothorax,  as  follows  : 

(i.)  Pulmonary  Excavation. — The  cavity  must  be  of  very 
considerable  size,  with  smooth,  firm  walls,  and  must  lie 
superficially.  It  must  contain  air,  and  must  be  in  free  com- 
munication with  a  bronchus.  In  such  vomicae  the  sonorous 
waves  excited  by  the  respiratory  current*  are  reflected 
again  and  again  from  the  smooth  walls,  and  so  come  to  have 
an  amphoric  character,  the  prime  tone  being  comparatively 
low  in  pitch,  and  the  upper  partials  high  and  ringing. 

(2.)  Pneumothorax. — When  air  escapes  into  the  pleural  sac 
and  distends  it,  the  lung  tissue  becomes  compressed  ;  and 

*  As  has  been  formerly  explained,  the  sonorous  waves  formed  in  a 
pulmonary  cavity  by  the  respiratory  air-current  are  the  result  of  sympa- 
thetic resonance. 


RESPIRATORY   SYSTEM.  169 

if  this  pressure  be  sufficient  not  only  to  drive  the  air  out  of 
the  air-cells,  but  also  to  cause  collapse  of  the  bronchi,  no 
amphoric  breathing  occurs.  But  if  the  fistula  by  which  the 
air  has  entered  becomes  closed  before  the  pressure  has  be- 
come sufficient  to  obstruct  the  bronchi,  the  bronchial  respi- 
ration will  be  conducted  to  the  immediate  neighborhood 
of  the  large  air  cavity  in  the  pleura,  in  which,  by  sympa- 
thetic resonance,  sonorous  vibrations  will  be  excited.  These 
vibrations,  owing  to  the  physical  conditions  met  with  in 
pneumothorax  (smooth,  firm  walls,  etc.),  will  have  an  am- 
phoric character.  If  some  quantity  of  serum  or  pus  be 
present,  along  with  air,  in  the  pleural  cavity,  the  pitch  of 
the  amphoric  sound  will  vary  according  to  the  position  of 
the  patient,  for  the  reason  already  mentioned. 

Thus  far  I  have  described  the  two  great  classes  of  respira- 
tory murmur,  the  bronchial  and  the  vesicular.  Between 
these  two,  however,  their  lies  an  intermediate  variety,  which 
may  be  called 

Broncho-vesicular  Breathing. 

There  may  occasionally  be  heard  a  respiratory  murmur 
which  even  the  most  practised  ear  cannot  define  as  being 
either  bronchial  or  vesicular.  This  murmur  may  be  pro- 
duced in  healthy  persons  when  they  are  directed  to  breathe 
superficially.  In  disease  this  variety  of  breathing  is  usually 
the  result  of  partial  blocking  up  of  the  bronchi  leading  to 
the  part  of  the  lung  examined,  or  to  the  interposition  of 
some  badly  conducting  substance  between  the  lung  and  the 
stethoscope,  such  as  pleural  effusion,  tumor,  or  even 
oedema  of  the  chest-wall. 

This  broncho-vesicular  murmur  is  only  of  diagnostic  value 
when  localized  in  one  particular  part  of  the  chest,  particularly 
when  it  is  confined  to  one  apex.  In  the  latter  case  it  points 
to  the  probability  of  commencing  phthisical  change. 


I70  MEDICAL  DIAGNOSIS. 

CHAPTER  XX. 

Respiratory  System — {Continued). 

ADVENTITIOUS    SOUNDS    ACCOMPANYING    RESPIRATION. 

» 

In  health  the  respiratory  murmur  is  not  accompanied  by 
any  other  sound,  but  in  the  great  majority  of  diseases  of  the 
lungs,  at  some  part  of  their  course,  there  become  audible 
certain  abnormal  or  adventitious  sounds  which  are  collec- 
tively known  under  the  term  rales.  Inasmuch  as  certain 
of  these  rales  give  to  the  ear  the  impression  of  being  caused 
by  the  bursting  of  air  bubbles  in  a  fluid,  while  others  have 
a  dry  snoring  or  whistling  character,  they  have  been  divided 
into  two  classes — moist  and  dry  rales.  Although  this  divi- 
sion is  not  scientifically  accurate,  some  of  the  apparently 
moist  sounds  being  in  reality  formed  without  the  presence 
of  fluid,  and  certain  of  the  dry  rales  owing  their  production 
to  the  presence  of  a  more  or  less  viscid  secretion,  yet  the 
division  is  clinically  useful,  and  ought  not,  I  think,  to  be 
discarded. 

Physicians  differ  much  in  regard  to  the  nomenclature  of 
these  rales,  and  as  a  rule  they  have  been  too  minutely  sub- 
divided. For  all  practical  purposes  the  following  classifi- 
cation will  be  sufficient : 

1.  Moist  rales — 

{a.)  Crepitation. 

{b.)  Fine  bubbling  rales. 

(c.)  Coarse  bubbling  rales. 

2.  Dry  rales* — 

[a.)  Sonorous. 
{b.)  Sibilant. 

3.  Pleuritic  friction. 

Moist  Rales. 

Crepitant  Rale. 

The  peculiar  fine  moist  rale,  which  Laennec  described 
under  this  name,  has  been  compared  to  the  sound  produced 
by  rubbing  a  lock  of  hair  between  the  fingers  close  to  the 
ear,  or  to  the  crepitation  of  salt  when  thrown  upon  the  fire; 


*  Sometimes  the  term  rhonchus  is  reserved  for  the  dry  sounds. 


RESPIRATORY   SYSTEM.  17I 

but,  as  Eichhorst  points  out,  both  these  sounds  are  too 
coarse,  and  crepitation  may  be  more  closely  imitated  by 
firmly  pressing  the  moistened  thumb  against  the  forefinger, 
and  then  suddenly  separating  the  two  surfaces,  close  to  the 
ear. 

Although  crepitation  is  probably  sometimes  due  to  the 
bursting  of  fine  bubbles  in  the  very  smallest  bronchioles,  it 
commonly  arises  from  the  sudden  separation  of  the  alveolar 
walls,  which  have  become  adherent  either  to  each  other  or 
to  a  mass  of  viscid  secretion  in  the  air  cell.  It  is  typically 
met  with  in  the  first  stage  of  pneumonia,  of  which  it  is  a 
most  important  sign,  and  it  also  occurs  in  pulmonary  collapse 
and  oedema.* 

Crepitation  occurs  almost  invariably  only  during  inspira- 
tion, and  is  usually  limited  to  the  latter  part  of  it  alone. 
The  individual  crepitations  of  which  it  is  composed  are 
characteristically  uniform  in  size,  and  are  unaffected  by  the 
act  of  coughing. 

Occasionally  in  health  a  momentary  crepitation  may  be 
heard,  usually  at  the  lower  posterior  border  of  the  lung,  but 
sometimes  also  at  the  apex,  w^hen  a  deep  inspiration  is 
made,  more  especially  when  the  patient  has  been  lying  on 
his  back,  and  the  respiration  has  been  very  quiet  for  some 
hours.     A  knowledge  of  this  fact  will  prevent  any  mistake. 

Fine  bubbling  rales. 

Coarse  bubbling  rales. 

These  two  varieties  of  rale  being  closely  associated,  they 
may  conveniently  be  considered  together.  The  difference 
in  the  size  of  the  bubbles  in  each  case  depends  somewhat 
upon  the  quantity  and  quality  of  the  fluid  in  which  they 
originate,  but  chiefly  upon  the  size  of  the  space.  The  finer 
bubbling  rales  arise  for  the  most  part  in  the  smaller  bronchi, 
the  coarser  in  the  large  bronchi,  in  the  trachea,  or  in  pul- 
monary cavities.  In  the  great  majority  of  cases  in  which 
these  bubbling  rales  are  heard,  they  vary  in  size,  and  are 
therefore  spoken  of  as  irregular,  in  contradistinction  to  the 
regular  fine  crepitant  rale  which  has  just  been  described. 

Arising  in  fluid,  as  these  bubbling  rales  do,  we  would 
naturally  expect  that  they  would  be  found  most  abundantly 
in  the  lower  portions  of  the  lung — the  fluid  obeying  the  law 

*  In  oedema  bubbling  rales  are  superadded,  owing  to  the  bronchi  being 
filled  with  fluid,  and  hence  the  uniformity  of  the  crepitation  is  lost.  The 
sourtd  is  thus  easily  distinguished  from  the  crepitant  rale  of  pneumonia. 


1/2  MEDICAL   DIAGNOSIS. 

of  gravity — and  this  is  generally  the  case,  the  base  of  the 
lung  posteriorly  being  their  most  common  seat.  When,  on 
the  contrary,  they  are  heard  most  abundantly  at  the  apices, 
and  still  more  when  they  are  exclusively  met  with  there  and 
persist  for  some  time,  the  condition  is  one  which  must  be 
looked  upon  with  considerable  gravity,  pointing  as  it  does 
to  a  local  cause,  which  in  the  majority  of  cases  is  some  form 
of  pulmonary  phthisis. 

The  finer  bubbling  rales  in  the  smaller  bronchi  occur 
chiefly  at  the  height  of  inspiration  and  the  beginning  of 
expiration,  while  coarse  bubbling  may  be  heard  both  during 
expiration  and  inspiration,  being  then  continuous.  In  both 
cases  a  severe  fit  of  coughing  may  remove  the  rales  for  the 
time.  Their  amount  and  intensity  depend  upon  the  quantity 
of  fluid,  the  nearness  of  the  bubbling  to  the  surface,  and  the 
strength  of  the  respiration. 

In  so  far  as  the  properties  of  these  bubbling  rales,  which 
have  as  yet  been  described,  go,  their  presence  only  informs  us 
that  the  air  current  encounters  fluid  in  the  respiratory  pas- 
sages, through  which  it  bubbles.  We  now  come  to  certain 
qualities  in  the  tone  of  these  rales  which  give  an  indication 
of  the  condition  of  the  surrounding  pulmonary  tissue.  If 
the  lung  tissue  around  the  point  at  which  the  bubbling  is 
taking  place  is  consolidated,  the  rales  assume  a  clear 
musical  high-pitched  quality,  and  are  termed  resonant. 
Whenever  such  rales  are  heard  we  may  conclude,  with 
safety,  that  consolidation  is  present  (although  their  ab- 
sence does  not  permit  of  the  exclusion  of  such  a  condition), 
and  in  fact  resonant  bubbling  has  a  significance  exactly 
similar  to  that  of  bronchial  breathing.  When  the  rales  oc- 
cur in  a  large  cavity  with  smooth  walls  and  near  to  the 
surface  of  the  lung,  they  assume  a  peculiarly  clear  metallic 
character — the  metallic  tinkling^  of  Laennec.  These  rales 
are  very  musical,  and  have  high  pitch  which  can  readily  be 
determined,  and  in  regard  to  their  physical  cause  and  the 
conditions  under  which  they  occur,  they  stand  in  close  re- 
lation to  amphoric  breathing  and  resonance.  Similar  reso- 
nant rales  may  be  heard  over  large  air  cavities  which  lie  in 
close  proximity  to  the  lungs,  such  as  a  pneumothorax,  or 
even  the  stomach  or  intestine  when  distended  with  air.     In 


*  This  tinkling  was  supposed  to  be  sometimes  produced  by  the  drop- 
ping of  fluid  from  the  roof  of  a  cavity,  but  this  manner  of  production 
would  seem  to  be  exceedingly  doubtful. 


RESPIRATORY    SYSTEM.  1 73 

such  cases  it  is  not  necessary  that  the  rales  arise  in  pul- 
monary cavities;  they  may  originate  simply  in  the  bronchi, 
and  the  neighboring  air  cavity  may  act  as  a  resonator,  re- 
producing and  intensifying  the  sound. 

Dry  Rales  are  produced  in  the  air  passages  by  any  patho- 
logical process  which  narrows  their  lumen,  the  most  com- 
mon being  the  accumulation  of  viscid  secretion  and  the 
swelling  of  the  mucous  membrane.  When  they  arise  in 
the  larger  bronchi  they  are  low-pitched  and  snoring  (sono- 
rous rales),  when  in  the  smaller  tubes  they  have  a  whistling 
character  (sibilant  rales).  Both  varieties  occur  chiefly 
during  inspiration,  the  snoring  rales  at  its  commencement, 
the  sibilant  not  till  towards  its  termination. 

Both  these  varieties  of  dry  rales  occur  in  cases  of  bron- 
chial catarrh,  whether  acute  or  chronic,  primary  or  second- 
ar}'',  and  according  as  they  are  sonorous  or  sibilant  we  may 
infer  that  the  larger  or  the  smaller  bronchial  tubes  are  af- 
fected. 

The  presence  of  pulmonary  consolidation  round  the 
point  at  which  these  rales  occur  imparts  to  them  a  ringing 
musical  character,  but  as  their  quality  is  in  any  case  musi- 
cal, this  change  has  not  anything  like  the  diagnostic  value 
which  it  possesses  in  the  case  of  moist  rales. 

Pleuritic  Friction. — The  gliding  of  one  pleural  surface 
over  the  other,  which  occurs  normally  with  each  respira- 
tion, is  accomplished  without  any  sound;  but  when,  as  the 
result  of  pleurisy,  the  surfaces  become  rough  and  uneven, 
sound  of  friction  becomes  audible.  This  sound  varies  from 
the  lightest  rubbing,  only  perceptible  with  difficulty,  to 
loud  creaking,  which  can  readily  be  made  out  on  palpation, 
and  which  the  patient  himself  both  feels  and  hears.  The 
sound  is  usually  broken  up  into  portions  of  greater  and  less 
intensity,  and  while  it  is  sometimes  audible  throughout  the 
whole  of  both  respiratory  phases,  it  is  usually  limited  to 
the  latter  portion  of  inspiration.  In  cases  of  pleurisy  the 
friction  sound  becomes  audible  whenever  the  process  has 
advanced  sufficiently  far  to  cause  considerable  roughness 
of  the  pleural  surfaces,  and  it  of  course  disappears  when 
those  surfaces  are  separated  by  effusion,  to  reappear  when 
absorption  of  the  fluid  has  taken  place.  Although  the 
friction  sound  may  sometimes  be  audible  over  a  great  part 
of  the  lung,  it  is  usually  limited  to  a  small  area,  and  occurs 


174  MEDICAL  DIAGNOSIS. 

most  frequently  in  the  axillary  region.  When  the  friction 
sound  is  heard  at  the  apex  of  the  lung  it  points  with  great 
probability  to  phthisis. 

With  regard  to  differential  diagnosis,  the  pleuritic  fric- 
tion-sound is  sometimes  closely  simulated  by  rales  in  the 
air  passages. 

Attention  to  the  following  points  will  usually  suffice  to 
distinguish  them: 

Rales.  Friction. 

Modified  by  coughing.  Not  modified  by  coughing. 

Not  affected  by  pressure      Intensified  by  pressure  of 
of  the  stethoscope.  stethoscope. 

Usually  heard  over  wide      Usually  localized, 
area. 

From  pericardial  friction  the  sound  of  pleuritic  friction  is 
easily  distinguished  by  making  the  patient  cease  breathing, 
when  the  latter  will  disappear  and  the  former  continue. 

Auscultation  of  the  Voice. — In  a  former  chapter,  the  fre- 
mitus, or  vibration  of  the  chest-walls,  produced  by  the  act 
of  speaking,  has  been  described.  As  regards  its  causation 
and  the  various  pathological  conditions  under  which  it  is 
enfeebled  or  intensified,  the  resonance  of  the  voice  closely 
corresponds  to  the  vocal  fremitus. 

When  the  stethoscope  is  applied  to  the  chest  while  the 
patient  speaks,  only  a  soft  indistinct  murmur  is  to  be  heard, 
provided  that  the  lung  is  healthy.  Over  the  larynx  and 
trachea,  however,  this  vocal  resonance  is  much  intensified, 
and  it  is  almost  as  though  the  words  were  spoken  into  the 
opening  of  the  stethoscope.  This  intensification  is  termed 
bj^onc/wphony.  * 

Before  speaking  of  changes  in  the  vocal  resonance  pro- 
duced by  pathological  conditions  connected  with  the  lung, 
it  may  be  as  well  to  repeat  what  was  said  in  connection 
with  vocal  fremitus — viz.,  that  the  vibrations  of  the  voice 
over  the  thoracic  parieties,  audible  as  well  as  perceptible 
to  palpation,  depend  for  their  intensity  upon  the  loudness 
and  depth  of  pitch  of  the  voice,  and  upon  the  thickness  of  the 
chest- wall;  that  the  vocal  resonance  (like   the  correspond- 

*  The  highest  development  of  bronchophony  was  termed  pectoriloquy 
by  Laennec,  but  there  is  no  fundamental  difference  between  the  two, 
and  there  seems  to  be  no  good  reason  for  adding  an  additional  term  to 
the  auscultatory  nomenclature,  which  is  already  sufficiently  complicated. 


RESPIRATORY   SYSTEM.  1/5 

ing  fremitus)  is  more  distinct  in  men  than  in  women;  and 
that  it  is  almost  invariably  louder  on  the  right  side  than 
on  the  left,  owing  to  the  larger  calibre  of  the  right  bron- 
chus. 

Bearing  these  points  in  mind,  we  may  now  consider  the 
changes  in  the  vocal  resonance  which  result  from  pulmo- 
nary disease. 

Enfeeblemetit  of  the  Vocal  Resona7ice. — The  vocal  resonance 
is  diminished  when  the  lung  is  separated  from  the  chest- 
wall  by  collections  of  liquid*  or  air  in  the  pleural  cavity, 
and  or  when  the  bronchi  leading  to  the  part  of  the  lung  in 
question  have  become  blocked  up  with  secretion. 

Intensification  of  the  Vocal  Resonance  {Bronchophony) . — As 
has  been  already  said,  bronchophony  occurs  normally  over 
the  larynx  and  trachea  down  to  the  bifurcation  of  the  latter 
in  the  interscapular  region.  When  bronchophony  occurs 
at  other  points  of  the  chest  it  is  pathological,  and  it  then 
owes  its  origin  to  consolidation  of  lung-tissue,  and  the  con- 
sequent better  conduction  of  the  vocal  vibrations  to  the 
chest-wall.  Bronchophony  thus  arises,  along  with  bron- 
chial respiration,  in  all  diseases  which  lead  to  condensa- 
tion— for  example,  in  acute  pneumonia,  and  in  all  the  forms 
of  phthisis.  It  is  particularly  noticeable  over  pulmonary 
vomicae,  the  resonance  of  the  air  in  the  cavity  adding  to  the 
intensity  of  the  vocal  resonance,  and  imparting  to  it  in  ad- 
dition a  peculiar  metallic  character.  As  a  whole,  it  may 
be  taken  that  bronchophony  has  an  exactly  similar  signifi- 
cance to  bronchial  respiration. 

It  has  been  said  that  pleural  effusions  diminish  or  even 
suppress  the  vocal  resonance;  but  this  is  not  always  the 
case.  Baccelli  pointed  out,  in  1875,  that  the  resonance  of 
the  whispered  voice  was  often  heard  very  clearly  over 
pleural  effusion.  "YYii^  pectoriloquie  aphonique  he  held  to  oc- 
cur only  when  the  fluid  was  homogeneous  (serous  effusion), 
and  was  not  present  when  the  effusion  was  heterogeneous 
(pus).  There  can  be  no  doubt  that  this  sign  is  very  fre- 
quently present  in  such  cases,  but  recent  observations! 
have  failed  to  confirm  its  value  in  so  far  as  the  discrimina- 
tion between  serous  and  purulent  effusions  is  concerned. 

Under  certain  conditions,  bronchophonic  vocal  resonance 
assumes  a  very  peculiar  nasal  quality,  resembling  the  noise 

*With  the  exceptions  to  be  presently  mentioned. 

f  Dr.  Douglas  Powell,  Tr.  International  Med.  Congress,  1881. 


1/6  MEDICAL  DIAGNOSIS. 

produced  by  speaking  against  a  comb  covered  with  paper, 
and  which,  from  its  supposed  resemblance  to  the  bleating 
of  a  goat,  Skoda  termed 

Aegophotiy. — This  variety  of  bronchophony  is  most  com- 
monly met  with  in  cases  of  pleuritic  effusion,  near  the  up- 
per margin  of  the  fluid,  and  usually  close  to  the  lower  angle 
of  the  scapula.  As  to  the  exact  manner  of  its  causation 
there  is  some  doubt,  but  most  observers  are  agreed  that  it 
depends  upon  compression  and  partial  obstruction  of  the 
bronchi.  Its  diagnostic  value  does  not  materially  differ 
from  that  of  ordinary  bronchophony. 

Hippocratic  Succussion. — We  must,  in  conclusion,  refer 
briefly  to  this  sign,  which  was  described  by  Hippocrates, 
and  which,  although  rarely  met  with,  is  of  considerable  in- 
terest. 

If,  in  cases  of  pyo-pneumothorax,  the  ear  be  applied  to 
the  chest  and  the  patient  shaken,  a  ringing  splashing  sound 
may  be  heard,  which  is  the  sign  in  question.  The  splash- 
ing noise  becomes  intensified  by  the  resonating  air  cavity 
above  the  fluid  in  the  way  I  have  already  described.  This 
succussion  sound  may  also  be  heard  when  there  is  a  very 
large  excavation  in  the  lung  tissue  partially  filled  with  fluid. 


CHAPTER  XXI. 

Integumentary  System. 


The  study  of  the  affections  of  the  skin  is  of  great  impor- 
tance to  the  physician,  not  merely  on  account  of  the  fre- 
quency of  their  occurrence,  the  distressing  severity  of  their 
symptoms,  and  the  deformities  which  they  leave  behind 
them  in  their  course,  but  also  because  they  are  frequently 
symptomatic  of  the  general  condition  of  the  system,  mirror- 
ing forth  with  fidelity  not  a  few  grave  systemic  diseases,  and 
still  more  often  the  many  slighter  disorders  which  it  is  impor- 
tant to  recognize  and  to  check  at  their  outset,  and  of  which 
the  physician  may  have  no  other  indication.     Among  the 

*  Dr.  Douglas  Powell,  Tr.  International  Med.  Congress,  1881. 


INTEGUMENTARY   SYSTEM.  T77 

serious  diseases  of  which  the  condition  of  the  skin  gives  ev- 
idence, it  is  hardly  necessary  to  mention  syphilis,  scrofula, 
as  well  as  all  the  members  of  the  important  group  of  exan- 
themata. Then,  again,  it  is  well  known  that  errors  in  diet, 
and  disorders  of  the  digestive  functions  generally,  are  apt 
to  cause  various  forms  of  skin  disease  (urticaria,  acne,  etc.), 
and  without  going  further  into  detail  in  illustration  of  this 
point,  it  may  finally  be  mentioned  that  many  uterine  affec- 
tions, and  even  pregnancy  itself  may  be  accompanied  with 
blotches  on  the  skin  (chloasma  uterinum),  which  in  certain 
circumstances  may  be  a  symptom  of  not  a  little  impor- 
tance. 

Subjective  Symptoms  are  of  comparatively  little  diagnostic 
importance  in  cases  of  skin  disease, although  to  the  patienc 
they  are  often  very  distressing.  Sensations  of  heat  attend 
all  the  inflammatory  processes  in  the  skin.  Hyperaesthesia 
and  anaesthesia  are  met  with  in  the  various  cutaneous  neuro- 
ses,and  shooting  pain  is  a  prominent  symptom  of  herpes  zos- 
ter, frequently  preceding  the  eruption,  and  persisting  for 
some  time  after  its  disappearance.  But  of  all  the  subjective 
symptoms  of  skin  disease,  the  most  distressing  is  itching. 
It  is  very  common  as  a  result  of  the  presence  of  parasites, 
but  frequently  occurs  independently  of  such  agents  in  cases 
of  eczema  and  of  pruritus. 

Objective  Symptoms. — A  patient  suffering  from  skin  disease 
ought  to  be  examined  in  a  well-lighted  and  warm  room, 
preferably  by  daylight,  and  if  a  male  the  whole  surface  of 
the  body  ought  to  be  viewed  by  the  physician  if  the  case  is 
at  all  important. 

The  general  condition  of  the  skin  as  to  color  and  moist- 
ure, the  deposit  of  subcutaneous  fat,  and  the  presence  of 
oedema  and  of  emphysema  are  points  which  have  been  al- 
ready considered  in  Chapter  I.,  and  need  not  be  again  re- 
ferred to. 

There  only  remain,  therefore,  for  our  consideration,  the 
various  eruptions  which  occur  on  the  skin. 

Eruptions. 

In  considering  skin  eruptions,  there  are  four  main  points 
to  which  attention  should  be  directed,  and  under  which  the 
facts  observed  may  be  satisfactorily  classified. 


178  MEDICAL  DIAGNOSIS. 

I.   The  Distribution  and  Configuration  of  the  Eruption. 

When  the  whole  surface  of  the  body  is  covered,  the  erup- 
tion is  said  to  be  universal;  when  it  is  irregularly  scattered 
over  various  parts  of  the  body,  it  is  said  to  h^  diffused.  The 
configuration  of  the  individual  lesions  is  commonly  defined 
by  such  terms  as  punctate  when  of  the  size  of  pin -heads, 
^i^iittate  when  resembling  drops  of  water,  nummular  when  of 
the  size  of  coin,  etc. 

The  distribution  of  the  lesion  is  often  of  considerable  di- 
agnostic importance.  For  example,  psoriasis  is  usually  only 
found  on  the  extensor  aspect  of  the  limbs,  whereas  the  mac- 
ular, papular,  and  squamous  syphilides,  when  they  appear 
on  the  limbs,  are  seen  on  the  flexor  surfaces.  Then,  again, 
certain  lesions,  as  herpes  zoster,  follow  the  course  of  nerves. 
Lupus  is  usually  found  on  the  face,  erythema  nodosum  on 
the  leg,  seborrhaea  sicca  on  the  scalp,  acne  on  the  face  and 
back,  and  the  scabies  insect  selects  for  its  burrows  by  pref- 
erence the  skin  between  the  fingers. 

2.    The  Elements  of  the  Skin  Involved. 

Careful  inspection  of  the  skin  will  inform  the  physician 
as  to  the  condition  of  the  epidermis,  the  hair,  the  orifices  of 
the  hair  follicles,  the  sebaceous  and  the  sweat  glands.  Pal- 
pation of  the  skin  will  further  give  information  regarding 
the  condition  of  the  true  skin,  whether  it  be  infiltrated  or 
not.  Pressure  with  the  finger  on  a  pigmented  spot  will 
show  whether  the  coloration  is  due  to  hemorrhage  or  to 
hypersemia,  for  in  the  latter  case  the  color  will  disappear  on 
pressure.  Further,  if  the  skin  be  covered  with  crusts,  the 
removal  of  these  by  means  of  the  finger  will  display  the 
condition  of  true  skin,  which  in  cases  of  eczema,  forexample, 
may  be  found  to  be  moist,  in  seborrhaea  dry,  and  in  psoria- 
sis bleeding.  We  have  further  in  the  diagnosis  of  skin  cases 
to  rely  upon  the  evidence  afforded  by  the  microscopic  exam- 
ination of  the  hair,  crusts,  etc.,  as  will  be  more  particularly 
pointed  out  when  we  come  to  speak  of  the  aetiology  of  such 
affections. 

3.   The  Type  of  the  Eruption, 

The  very  numerous  forms  assumed  by  skin  eruptions  may 
be  defined  and  described  as  follows: 

(a.)  Macules  i^Maculce). — These  consist  in  morbid  changes 


INTEGUMENTARY   SYSTEM.  T^Q 

in  the  color  of  the  skin,  which  are  circumscribed,  and  do  not 
involve  the  whole  cutaneous  surface,  and  which  are  neither 
elevated  above  nor  depressed  below  the  surface  of  the  skifi. 
Such  macules  may  arise  in  very  various  ways.  Sometimes,  as 
in  Erythema  fuga*x,  they  are  occasioned  by  hyperaemia,  and 
then  the  color  disappears  on  pressure;  sometimes  by  hem- 
orrhage, as  in  purpura;  by  increase  or  decrease  of  the  nor- 
mal pigment;  by  exudations  into  the  tissues  of  the  true 
skin,  as  in  syphilides;  and,  finally,  they  sometimes  arise 
from  increase  in  the  size  and  number  of  the  blood-vessels, 
as  in  naevi. 

(d.)  Papules  (Papulce)  are  small  firm  elevations  above  the 
surface  of  the  skin,  varying  in  color,  and  arising  in  very 
different  ways.  The  simplest  form  of  papule  is  seen  in  the 
ctitis  anserina  or  goose-skin,  due  to  the  contraction  of  the 
muscles  of  the  skin.  Pathologically,  papules  form  as  the 
result  of  hypertrophy  of  the  papillae  (ichthyosis),  of  cell 
proliferation  in  these  structures  (lupus,  syphilis),  or  of 
inflammation  of  and  consequent  exudation  into  these 
papillae,  as  in  eczema  papulosum.  Extravasation  of  blood 
into  the  skin  may  give  rise  to  papules,  as  is  seen  in  purpura 
papulosa.  Papules  may  also  be  formed  in  connection  with 
the  sebaceous  glands  (milium,  comedo,  acne),  or  by  accu- 
mulation of  epidermic  cells  round  the  hair  follicles,  as  in 
lichen  pilaris. 

(r.)  Tubercules  {tuherculd)  are  simply  exaggerated  papules. 
They  are  usually  occasioned  by  cell  proliferation,  and  occur 
as  the  result  of  syphilis,  carcinoma,  leprosy,  etc, 

(^. )  Tu?nors  {^phyinatd)  hardly  require  a  definiton  here. 
They  may  be  of  considerable  size,  even  as  large  as  a  child's 
head.  Examples  are  seen  in  molluscum,  and  in  the  various 
cystic  growths  met  with  in  connection  with  the  skin. 

(<?.)  Wheals  {pompki)  are  flat,  irregularly-shaped,  firm, 
elevations  on  the  skin,  pale  in  the  centre,  red  at  the  edges, 
and  which  are  very  fugitive.  Wheals  are  typically  seen  as 
the  result  of  the  sting  of  the  nettle,  and  in  urticaria.  They 
result  from  sudden  effusion  of  the  serum  into  the  papillae, 
and  swelling  of  the  cells  of  the  rete  malpighii,  produced 
probably  by  vasomotor  changes. 

(/".)  Vesicles  {vesiculce)  are  small  rounded  elevations  of  the 
cuticle,  varying  in  size  up  to  that  of  a  split  pea,  containing 
serous,  sero-purulent,  or  bloody  fluid,  and  either  lying 
between  the  mucous  and  horny  layers  of  the  epidermis,  or 


l80  MEDICAL  DIAGNOSIS.  ' 

in  connection  with  the  hair  follicles,  or  with  the  sebaceous 
or  sweat  glands, 

(g.)  Blebs  {bulled)  only  differ  from  vesicles  in  point  of  size, 
being  larger  than  a  split  pea. 

(/z.)  Pustules  (pusfulce)  are  elevations  'of  the  epidermis, 
similar  in  shape  to  vesicles  and  blebs,  but  containing  pus. 
They  are  sometimes  found  in  substance  of  the  true  skin 
(boils),  in  connection  with  hair  follicles  (as  in  sycosis),  or  in 
sebaceous  glands  (acne),  or  between  the  mucous  and  horny 
layers  of  the  epidermis,  as  in  smallpox.  Pustules  usually 
dry  up  (with  or  without  bursting)  into  yellow  or  brownish 
crusts,  and  very  often  leave  permanent  cicatrices,  if  the 
tissues  of  the  true  skin  have  been  involved. 

Thus  far,  we  have  been  considering  what  are  called  the 
primary  lesions,  and  we  now  pass  to  those  which  are  sec- 
ondary. 

(/.)  Excoriations  are  breaches  of  the  continuity  of  the  skin, 
produced  most  usually  by  the  patient's  nails.  They  give  an 
indication  of  the  amount  of  itching  which  is  present.  When 
lice  are  present  (phthiriasis),  the  marks  of  the  scratches  are 
long  and  straight;  in  pruritus,  they  are  short  and  irregular; 
and  in  scabies,  small  and  round. 

(/)  Scales  {squamice)  are  portions  of  epidermis  which  have 
become  separated  by  diseased  processes  in  the  skin.  The 
deeper  and  more  severe  the  inflammation,  the  more  marked 
is  the  desquamation.  The  scales  may  be  thrown  off  as  fine, 
branlike  particles  (as  in  prurigo,  pityriasis,  measles,  etc.), 
or  as  thin  flakes  or  thick  plates  (in  psoriasis,  and  eczema)  ; 
or  the  epidermal  layer  to  be  thrown  off  may,  as  in  scarla- 
tina, separate  as  a  whole,  forming  a  more  or  less  perfect 
cast  of  the  fingers,  or  even  of  the  whole  hand. 

{k.)  Crusts  are  formed  by  the  drying  up  of  the  products 
of  skin  disease,  serum,  pus,  blood,  etc.  When  chiefly  com- 
posed of  pus,  they  have  a  greenish  color;  when  mixed  with 
blood,  the  crusts  are  brown  or  black.  The  firmest  and 
hardest  crusts  are  those  met  with  in  syphilitic  processes 
(rupia),  when  they  often  assume  a  form  closely  resembling 
that  of  a  limpet  shell.  The  crusts  of  favus  are  yellow  and 
cup-shaped. 

(/.)  Fissures  {rhagades)  in  the  skin  may  involve  the  epi- 
dermis alone,  or  both  the  epidermis  and  the  true  skin  ;  or 
they  may  be  seated  in  mucous  membrane.  They  are  usually 
found  where  the  skin  is  normally  furrowed — as,  for  example, 
on  the  palms  of  the  hands  and  soles  of   the  feet ;  at  the 


INTEGUMENTARY    SYSTEM.  l8l 

angles  of  the  mouth  ;  where  the  upper  lip  and  nose  join  ; 
at  the  elbows  and  knees  ;  at  the  anus,  and  in  other  similar 
situations.  Fissures  are  found  in  cases  of  chronic  eczema 
and  inveterate  psoriasis,  in  syphilis,  and  in  scleroderma. 

(;;/.)  Ulcers  are  chiefly  within  the  domain  of  surgery. 
Their  size,  depth,  shape,  situation,  and  general  condition 
should  be  noted. 

(«.)  Cicatrices  follow  all  diseases  or  injuries  of  the  skin 
which  involve  loss  of  substance.  The  character  of  the  scar 
is  not  indicative  of  the  preceding  disease  ;  but  sometimes 
the  number  or  seat  of  the  cicatrices  may  afford  some  indi- 
cation of  their  cause. 

4.    The  Etiology  of  the  Eruption. 

Skin  eruptions  are  much  influenced  by  the  age  and  sex 
of  the  patient,  by  the  season  of  the  year,  and  by  climate. 
On  these  points,  and  on  the  heredity  of  many  such  diseases, 
we  need  not  now  dwell.  Very  frequently  skin  affections 
are  the  result  of  constitutional  diseases,  as,  for  example, 
purpura,  scrofula,  rickets,  all  the  acute  exanthemata,  dia- 
betes, etc.  We  have  further  to  note  that  diseases  of  partic- 
lar  organs  often  give  rise  to  skin  eruptions.  Disorder  of 
digestion  from  improper  diet  (shell-fish,  for  example),  or 
other  cause,  is  frequently  followed  by  urticaria  and  acne. 
In  valvular  disease  of  the  heart,  oedema  and  small  hemor- 
rhagic extravasations  (petechiae)  frequently  occur.  Bright's 
disease  is  often  accompanied  by  pruritus,  and  sometimes  by 
eczema.  Many  other  instances,  too  numerous  to  mention 
here,  will  occur  to  the  reader  in  which  diseases  of  the 
different  internal  organs  are  accompanied  by  skin  eruptions 
which  are  more  or  less  characteristic. 

A  class  of  eruptions  with  which  it  is  very  important  that 
the  physician  should  be  familiar  are  those  which  result  from 
internal  and  external  use  of  certain  medicines. 

All  counter-irritants — such  as  croton  oil,  mustard,  cantha- 
rides,  tartar-emetic,  iodine,  turpentine,  arnica,  etc. — give  rise 
to  various  forms  of  dermatitis;  as  do  also  the  various  aniline 
colors  with  which  stockings  are  sometimes  dyed. 

The  internal  administration  of  medicines  is  occasionally 
followed  by  skin  eruptions,  a  result  which  is  most  frequently 
due  to  some  peculiar  idiosyncrasy  of  the  patient.  Among 
these  may  be  mentioned  the  acne  pustules  which  follow  the 
use  of  the  bromides,  the  erythema  (or  even  eczema)  of  the 


1 82  MEDICAL  DIAGNOSIS. 

iodides,  and  the  scarlatina-like  efflorescence  of  chloral. 
Very  characteristic  of  atropia-poisoning  are  the  bright  ery- 
thematous patches  which  appear  on  the  chest  and  neck. 
Morphia  sometimes  gives  rise  to  an  erythematous  eruption 
resembling  that  of  scarlatina,  and  the  administration  of 
quinine  is  occasionally  followed  by  a  rash  of  the  same 
description.  The  eruption  of  copaiba  usually  shows  itself 
upon  the  extremities  as  a  bright  papular  efflorescence,  which 
is  generally  very  itchy. 

Among  the  causes  acting  locally  in  the  production  of  skin 
eruptions  may  be  mentioned  (in  addition  to  the  external 
applications  just  noticed)  the  following:  Continued  expo- 
sure to  the  heat  of  a  strong  fire  is  apt  to  give  rise — in 
furnacemen  and  cooks,  for  example — to  eczema.  Those 
who  work  in  acids  or  alkalies,  and  especially  in  aniline  dyes, 
suffer  much  from  eczema.  Even  the  long  soaking  of  the 
hands  and  arms  in  hot  water  and  soap  produces  in  washer- 
women a  hardened,  fissured,  and  even  eczematous  condition 
of  the  skin  of  these  parts.  The  most  important  local  cause 
of  skin  eruptions  is,  however,  undoubtedly  to  be  found  in 
the  irritation  set  up  by  the  various  parasites  which  infest 
the  skin  and  hair.  The  diagnosis  in  such  cases  is  closely 
bound  up  with  the  etiology,  and  they  must  be  considered 
together.  The  parasites  which  affect  the  skin  belong  to  both 
the  animal  and  vegetable  kingdoms.  The  most  important 
of  these  are  the  following  : 


Vegetable  Parasites, 

I.  Achorion  Schonleinii. — This  parasite  gives  rise  to  the  dis- 
ease known  as  tinea  favosa,  or  favus.  While  it  occasion- 
ally attacks  the  nails,  it  is  most  usually  found  upon  the 
scalp,  where  it  gives  rise  to  the  formation  of  light-yellow, 
dry,  cupped  crusts.  The  hair  follicle  and  hair  are  first  at- 
tacked, and  then  the  parasite  spreads  itself  upon  the  surface 
of  the  skin.  When  a  part  of  one  of  these  crusts  is  exam- 
ined with  the  microscope,  after  having  been  soaked  in 
water,  and  treated  with  acetic  acid  or  an  alkali,  the  parasite 
(fig.  6)  is  readily  recognized.  It  consists  (i)  of  spores;  (2) 
of  slightly  elongated  elements,  which  are  usually  united  in 
rows;  and  (3)  of  mycelium,  which  is  made  up  of  long, 
branching,  transparent  filaments,  which  may  or  may  not 
contain  spores  in  their  interior.     In  the  favus  crust  there 


INTEGUMENTARY   SYSTEM. 


183 


are  always  to  be  found,  in  addition,  numerous  micrococci 
and  bacteria. 

2.  Trichophyton. — This  parasite  produces  three  forms  of 
skin  disease — tinea  circinata,  or  ringworm  of  the  body; 
tinea  tonsurans,  or  ringworm  of  the  scalp;  and  probably 
tinea  sycosis,  or  sycosis  parasitica,  a  similar  affection  of  the 
beard  and  other  hairy  portions  of  the  face.  On  the  body, 
the  trichophyton  gives  rise  to  considerable  irritation  of  the 


Fig.  6. — Achorion  Schonleinii  (Duhring), 

skin,  which  results  in  the  formation  of  circular  circum- 
scribed patches  of  various  size,  slightly  elevated  above  the 
level  of  the  skin,  of  a  dull  red  color,  and  usually  covered 
with  small  branny  scales,  while  round  the  edges  there  may 
be  found  vesicles,  and  sometimes  even  pustules. 

On  the  scalp,  ringworm  shows  itself  as  one  or  more  cir- 
cumscribed patches  of  a  grayish  or  slightly  ruddy  color. 
The  hair  of  the  affected  parts  is  short,  lustreless,  easily 
drawn*out,  breaks  readily,  and  the  extremities  are  ragged 


1 84 


MEDICAL  DIAGNOSIS. 


and  uneven.    The  skin  is  covered  with  numerous  thin  white 
scales,  and  occasionally  with  crusts. 

On  the  beard  and  upper  lip,  the  parasitic  form  of  sycosis 
— which  is  probably  caused  by  the  trichophyton— at  first 
exhibits  characters  closely  resembling  those  of  ringworm 
of  the  scalp.  As  the  disease  advances,  however,  the  skin 
and  deeper  parts  become  inflamed  and  indurated,  and,  as  a 


Fig.  7.— Hair  affected  with  Tinea  Tonsurans  (Neumann). 

consequence,  the  affected  portions  become  covered  with 
characteristic  tubercular  elevations,  and  pustules  occupy 
the  hair  follicles. 

In  all  these  situations  the  trichophyton  presents  similar 
microscopic  appearances.  In  the  case  of  tinea  circinata,  a 
few  of  the  scales  should  be  scraped  off  the  patch  with  a 
penknife,  laid  on  a  microscopic  slide  and  examined,  after 
the  addition  of  a  dilute  solution  of  carbonate  of  potassium. 
In  the  other  forms,  a  diseased  hair  should  be  extracted  and 
examined,  after  the  addition  of  liquor  potassse  or  chloro- 


INTEGUMENTARY   SYSTEM. 


185 


form.  Whether  in  the  hair  (as  in  fig.  7)  or  spread  over  the 
surface  of  the  skin,  the  parasite  will  be  found  to  consist  of 
long,  slender,  jointed  filaments  (mycelium),  together  with 
small,  round,  highly  refractive  spores.  The  latter  are  most 
abundant  in  ringworm  of  the  scalp,  infiltrating  densely  the 
hair  bulb,  while  the  mycelium  spreads  up  the  shaft  of  the 
hair.* 

3.  Microspo7-on  Furfur  is  the  parasite  which  gives  rise  to 
pityriasis  versicolor.  This  disease  is  characterized  by  the 
presence  on  the  skin  (usually  of  the  back  and  chest)  of  va- 
riously-sized pale  yellowish-brown  or  reddish  patches  cov- 
ered with  fine  powdery 
scales.  It  is  most  frequent- 
ly met  with  in  those  suf- 
fering from  wasting  dis- 
eases. The  microsporon 
furfur  consists  of  spores 
and  mycelium.  The 
spores  are  small,  round  or 
oval,  highly  refractive  bod- 
ies, which  tend  to  arrange 
themselves  in  groups  in  a 
manner  which  is  very  char- 
acteristic of  this  parasite. 
The  mycelium  consists  of 
fine  curved  filaments  which 
are  usually  short  and  are 
jointed  together,  forming  a 
close  netw^ork.  In  their 
interior  spores  are  general- 
ly to  be  seen. 

This  parasite  is  very 
readily  detected  by  means 
of  the  microscope.  A  few 
of  the  scales  on  the  surface 
of  the  patch  should  be 
scraped  off  with  the  pen- 
knife, placed  upon  a  cover-  F'^-  8-— Microsporon  Furfur  (Neumann), 
glass,  and  treated  with  liq.  potassae.f 

*  It  is  very  probable  that  a  form  of  eczema  which  affects  the  inner  sur- 
faces of  the  thighs  (eczema  marginatum)  also  owes  its  origin  to  the  pres- 
ence of  the  trichophyton. 

f  The  patches  of  baldness  of  alopecia  areata  are  by  some  supposed  to 
be  parasitic,  and  to  depend  on  the  presence  of  the  inicrosporon  audoini, 
but  there  is  considerable  uncertainty  on  this  point. 


1 86 


MEDICAL  DIAGNOSIS. 


Animal  Parasites, 

I.  Sarcoptes  Scabiei. — The  skin  disease — scabies,  or  the  itch 
— which  is  caused  by  presence  of  this  insect,  consists  of 
papules,  vesicles,  pustules,  excoriations,  fissures,  crusts;  in 
short,  an  eczema,  in  the  neighborhood  of  the  burrows  in 
which  the  insects  lie.  Scabies  is  usually  found  between  the 
fingers,  but  may  spread  over  the  body  generally,  the  insect 
selecting,  however,  localities  where  the  skin  is  soft  and  thin. 
It  is  the  commonest  of  all  skin  diseases,  and  is  very  con- 
tagious. 

The  female  insect,  which 
can  be  seen  in  fig.  9  lying 
at  the  end  of  its  burrow, 
has  an  oval  body,  marked 
with  fine  undulating  lines, 
a  small  oval  head,  and  pos- 
sesses eight  legs  (the  four 
front  legs  being  furnished 
with  suckers)  and  num- 
erous bristles.  The  male 
insect  does  not  give  rise  to 
the  eruption,  and  is  but 
seldom  met  with.  The 
female,  after  being  im- 
pregnated, bores  through 
the  horny  layer  of  the 
cuticle  perpendicularly, 
and  then  forms  a  burrow 
which  runs  horizontally  in 
the  mucous  layer  of  the 
epidermis.  This  burrow, 
or  cuniculus,  can  often  be 
seen  by  the  naked  eye  as  a 
whitish  elevated  line  ter- 
minating in  a  minute  speck, 
which  is  the  insect.  The 
cuniculus  becomes  filled 
with  eggs,  of  which  the  in- 
sect lays  about  ten  to  fif- 
teen, and  with  small  black 
specks  of  excrement.  The  eggs  are  hatched  in  about  ten 
days. 

With  a  little  trouble  the  itch  insect  can  usually  be  se- 


Fig.  9.    Sarcoptes  Scabiei  (Neumen). 


IMTEGUMENTARY   SYSTEM.  1 8/ 

cured,  and  the  diagnosis  thereby  rendered  certain.  A 
needle  should  be  introduced  into  the  burrow,  which  the  in- 
sect will  generally  seize  hold  of,  and  on  the  point  of  which 
it  may  be  removed. 

2.  Pediculus. — Three  varieties  of  pediculi  are  met  with  on 
the  human  body,  giving  rise  to  the  disease  termed  phthiri- 
asis — the  pediculus  capitis,  pediculus  corporis,  and  pedi- 
culus pubis. 

The  head  louse  is  an  elongated  ovalish  insect  of  a  grayish 
hue.  From  its  head  spring  two  antennae,  each  consisting 
of  five  parts,  and  to  the  thorax  are  articulated  six  legs 
armed  with  strong  claws.  The  oval  whitish  eggs  are  firmly 
fastened  to  the  hairs  of  the  patient's  head  by  means  of  a 
viscid  glue-like  material.  The  irritation  and  itching  of  the 
scalp  and  the  consequent  scratching  give  rise  to  a  severe 
eczematous  condition,  in  which  the  serous,  sanguineous, 
and  purulent  exudations  matt  together  the  hairs,  and  almost 
invariably  cause  enlargement  of  the  neighboring  lymphatic 
glands. 

The  pediculus  corporis,  or  pediculus  vestimenti,  as  the 
insect  is  sometimes  termed,  resembles  closely  the  head  louse 
in  structure,  but  is  somewhat  larger.  The  cutaneous  lesions 
consist  chiefly  in  long  scratch  marks,  crusts,  and  papules, 
along  with  the  minute  red  points  where  the  insect  has  bit- 
ten. 

The  pediculus  pubis,  or  crab-louse,  is  smaller  and  more 
rounded  than  either  of  the  other  species.  It  infests  chiefly 
the  pubic  region,  and  usually  gives  rise  to  considerable 
irritation. 

3.  Pulex  Irritans,  the  common  flea,  need  hardly  be  men- 
tioned here,  were  it  not  that  flea-bites  are  occasionlly  mis- 
taken for  purpuric  spots.  Round  the  bite,  however,  there 
will  be  seen  to  be  a  hyperaemic  areola,  which  is  not  met 
with  in  purpura. 

4.  Demodex  Folliculorum  is  a  harmless,  worm-like  parasite, 
which  inhabits  the  sebaceous  follicles  of  the  skin  of  the 
face.  If  the  contents  of  a  prominent  follicle  be  squeezed 
out  and  examined  with  the  microscope,  the  demodex  will 
be  found. 


1 88  MEDICAL   DIAGNOSIS. 

CHAPTER  XXII. 

Urinary  System. 

subjective  symptoms. 

Before  proceeding  to  the  consideration  of  the  various 
changes  met  with  in  the  urine  in  disease,  which  must  al- 
ways rank  as  the  most  important  sign  of  urinary  disorders, 
it  may  be  well  to  note  certain  subjective  symptoms  which 
occur  in  such  cases,  and  which  often  give  very  valuable  in- 
dications. 

Pain  may  be  felt  at  different  portions  of  the  urinary  tract, 

as  follows  : 

1.  At  the  end  of  the  Penis. — In  calculus  of  the  bladder  pain 
is  felt  after  micturition,  because  the  rough  stone  then  comes 
in  contact  with  the  bladder  wall  ;  it  is  referred  chiefly  to 
the  extremity  of  the  penis,  and  is  increased  by  any  sudden 
movement.  In  prostatitis,  also,  pain  occurs  after  passing 
water,  the  bladder  then  contracting  on  the  tender  prostate. 
In  women  there  is  often  severe  pain  felt  during  micturition 
at  the  orifice  of  the  urethra,  owing  to  the  presence  there  of 
a  small  vascular  growth. 

2.  In  the  course  of  the  Urethra. — When  the  urethral  canal  is 
narrowed  by  stricture,  pain  is  felt  at  the  constricted  point 
during  micturition.  In  urethritis,  also,  the  pain  during  the 
passing  of  water  is  referred  to  the  urethra.  When  the  urine 
is  highly  acid,  concentrated,  or  contains  gravel,  urethral 
pain  also  occurs  during  micturition. 

3.  Over  the  Bladder  in  the  Supra-Pubic  Regio7i. — This  is  the 
common  seat  of  the  pain  of  cystitis,  which,  it  is  to  be  ob- 
served, occurs  before  micturition,  and  is  relieved  by  that 
act.  In  acute  cases  pain  may  also  be  felt  deep  in  the  peri- 
neum. 

4.  In  the  Loijis.' — In  cases  of  pyelitis,and  of  renal  calculus 
there  is  usually  dull  aching  pain  over  the  loins,  which  is 
increased  on  pressure,  and  which  in  the  latter  disease  oc- 
casionally passes  into  violent  paroxysms,  the  pain  shooting 
down  the  ureters  to  the  testicle  and  inside  of  the  thigh. 

Frequency  of  Micturition. — Wherever  the  urine  is  large  in 


URINARY   SYSTEM.  189 

quantity,  as  in  diabetes  and  the  waxy  form  of  Bright's  dis- 
ease, for  example,  there  is  frequency  in  micturition.  This 
symptom,  however,  also  occurs  in  very  many  other  urinary 
disorders.  In  all  inflammatory  conditions  of  the  prostate 
and  bladder,  in  pyelitis,  and  nephritis,  in  calculus  of  the 
bladder  or  kidneys,  the  urine  is  frequently  voided.  It  is 
particularly  to  be  noticed  that  in  the  cirrhotic  or  contract- 
ing form  of  Bright's  disease,  and  in  hypertrophy  of  the 
prostate,  the  calls  to  micturate  are  frequent,  and  occur  chiefly 
during  the  night. 

The  Exa77iination  of  the  Urine. 

In  such  a  work  as  this  it  is  of  course  quite  impossible  to 
give  anything  like  an  exhaustive  account  of  the  many 
changes  which  take  place  in  the  urine  in  health  and  disease, 
or  of  the  various  methods  of  analysis  which  have  been 
applied  to  that  secretion.  All  that  I  shall  attempt  to  do 
will  be  to  enumerate  the  more  ordinary  and  clinically 
significant  changes  which  occur,  and  the  simpler  methods 
of  anal3^sis,  such  as  may  be  carried  out  by  the  physician, 
excluding  those  which  require  the  more  complicated  appa- 
ratus of  a  chemical  laboratory. 

In  the  present  chapter  we  shall  consider  the  general  con- 
dition of  the  urine  as  to  (i)  quantity,  (2)  color  and  trans- 
parency, (3)  odor,  (4)  specific  gravity,  and  (5)  reaction. 

I.  Quantity  of  the  Urine. — While  varying  according  to  the 
quantity  of  the  fluid  drunk,  the  amount  of  the  pulmonary 
and  cutaneous  transpiration,  and  of  the  alvine  discbarge,  the 
average  quantity  of  urine  voided  in  twenty-four  hours  may 
be  taken  to  be  in  the  adult  from  35  to  60  ounces. 

The  quantit3MS  diminished  in  all  febrile  diseases;  in  heart 
affections  when  compensation  is  lost,  in  cases  of  collapse,  and 
generally  in  all  these  conditions  in  which  much  fluid  is  pass- 
ing out  of  the  blood,  such,  for  example,  as  profuse  diarrhoea 
or  perspiration,  the  rapid  accumulation  of  serum  in  the  pleu- 
rae or  peritoneum,  etc.  Further,  there  is  scanty  urine  in  the 
inflammatory  form  of  Bright's  disease,  whether  there  be  in- 
flammation of  the  tubules  or  of  the  glomeruli.  The  urinary 
flow  may  be  completely  suppressed  in  cases  where  the  ureters 
are  occluded  by  the  impaction  of  calculi,  or  by  the  pressure 
of  morbid  growths. 

The  urinary  flow  is  i7icreasedhy  ih.^  administration  of  diu- 
retics.    It  is  greatly  augmented  in  cases  of  diabetes  insipi- 


190  MEDICAL  DIAGNOSIS. 

dus  and  mellitus,  chiefly  owing  to  the  large  quantities  of 
water  which  such  patients  drink.  In  the  cirrhotic,  or  con- 
tracting form  or  Bright's  disease,  the  quantity  of  urine  se- 
creted is  increased  in  the  later  stages,  when  the  heart  has  be- 
come hypertrophied,  and  the  vascular  tension  increased.  On 
the  other  hand,  in  the  waxy  form  (as  was  first  pointed  out 
by  Professor  Grainger  Stewart)  polyuria  is  an  early  symptom, 
often  occurring  even  before  the  presence  of  albumen  can  be 
detected. 

Color  of  theTJrine. — The  urine  owes  its  color  to  the  quan- 
tity of  pigment  it  contains,  and  to  the  amount  of  its  concen- 
tration— very  dilute  being  pale,  very  concentrated  having  a 
dark  brownish-red  color.  For  convenience  of  comparison, 
Vogel's  standard  scale  of  colors  is  usually  adopted.  The 
various  tints  are  grouped  as  follows: 

(  Pale  yellow, 
Yellow  Urines,      ■<  Bright  yellow, 

(  Yellow. 

I  Reddish- yellow, 
Red  Urines,  -<  Yellowish-red, 

(Red. 

(  Brownish-red, 
Dark  Urines,  <  Reddish-brown, 

(  Brownish-black. 

In  order  to  obtain  uniform  results  as  to  color,  the  urine 
should  be  examined  in  a  glass,  the  diameter  of  which  is 
about  four  inches;  and  if  not  absolutely  clear,  the  urine  must 
be  filtered  before  its  color  is  noted. 

Very  pale  urines  are  met  with  in  healthy  persons  after 
copious  draughts  of  water,  and  further,  in  cases  of  diabetes 
and  of  anaemia,  and  after  hysterical  paroxysms.  Highly- 
colored  urines  occur  in  the  febrile  state,  and  under  other 
pathological  conditions,  which  will  be  mentioned  more  par- 
ticularly hereafter. 

What  the  pigments  of  normal  urine  are  is  still  a  matter  of 
doubt.  There  are,  however,  two  pigments,  both  of  which 
must  be  looked  upon  as  pathological,  uro-bilin,  and  uro-ery- 
thrin,  about  which  a  few  words  must  be  said. 

Uro-bilin  is  a  reddish  pigment,  first  described  by  Jaffe,* 
which  is  found  in  considerable  quantity  in  the  urine  of  fever, 

*  Virchow's  Archiv.,  vols,  xlvii.  and  xlviii. 


URINARY   SYSTEM.  I9I 

and  sometimes  In  that  of  jaundice.  In  normal  urine,  when 
first  voided,  it  does  not  occur,  but  it  often  appears  after  the 
urine  has  been  allowed  to  stand  for  some  time  in  contact 
with  the  air.  The  chief  interest  of  uro-bilin  is  derived  from 
its  relations  with,  on  the  one  hand,  bilirubin,  which,  as  Maly  * 
lias  shown,  when  treated  with  sodium-amalgam,  yields  a 
body  which  he  named  hydro-bilirubin,  and  which  is  identical 
in  all  its  characters  with  uro-bilin;  and,  on  the  other  hand, 
with  blood  pigment,  for  Hoppe-Seyler  has  pointed  out  that 
when  haematin  in  alcoholic  solution  is  treated  with  tin  and 
hydrochloric  acid,  uro-bilin  is  formed.  The  detection  of  uro- 
bilin is  usually  easy,  and  depends  chiefly  upon  the  three  fol- 
lowing points:  (i.)  Examined  with  the  spectroscope,  most 
urines  which  contain  uro-bilin  show  an  absorption  line  be- 
tween Frauenhofer's  lines  b  and  F,  which  is  not  very  well  de- 
fined, and  which  shades  away  towards  F.  Sometimes,  how- 
ever, the  spectrum  cannot  be  made  out  in  the  urine  itself. 
In  such  cases  if  the  urine  be  shaken  up  with  ether,  the  ethe- 
rial  solution  of  the  pigment  will  show  the  spectrum  clearly. 
(2.)  When  a  small  quantity  of  chloride  of  zinc  is  added  to 
an  alkaline  solution  of  the  pigment,  a  green  fluorescence  ap- 
pears. (3.)  The  addition  of  ammonia  to  the  urine  itself,  or 
to  an  acid  solution  of  uro-bilin,  changes  the  reddish  color 
into  clear  yellow. 

Ui'O-erythrin  is  a  pinkish-red  pigment  (the  purpurin  of 
Bird)  which  often  appears  in  the  urines  of  fever,  and  of  cir- 
rhosis of  the  liver,  and  which  attaches  itself  to  precipitates  of 
urates  and  of  uric  acid,  giving  the  sediment  a  brick-dust 
color.  This  deposit,  however,  often  occurs  in  otherwise 
healthy  persons  from  errors  in  diet  and  other  slight  causes. 

Melanin,  the  black  pigment  which  is  found  in  the  urine  in 
cases  of  melanotic  cancer,  may  at  times  possess  some  diag- 
nostic significance. 

The  administration  of  certain  drugs  is  followed  by  altera- 
tion in  the  color  of  the  urine.  Thus  after  the  absorption  of 
carbolic  acid,  the  urine  becomes  of  a  dark  greenish-brown 
color,  due  to  the  presence  of  an  oxidation  product  of  hydro- 
chinon.  Rhubarb  and  senna  (chrysophanic  acid)  color  the 
urine  a  deep  brownish-yellow,  which  changes  to  bright  red 
on  the  addition  of  an  alkali.  Logwood  imparts  a  red  tinge, 
and  santonin  a  bright  yellow,  which  changes  to  orange  when 
ammonia  is  added. 


*  Centralbl.  f.  d.  Med.   Wissensch,  1871. 


192  MEDICAL  DIAGNOSIS. 

The  presence  of  blood  and  bile  pigments  in  the  urine  will 
be  considered  hereafter. 

Transparency. — Normal  urine,  when  freshly  passed,  is  al- 
most invariably  transparent;  but  when  allowed  to  stand, 
clouds  of  mucus  form  in  it,  which,  at  the  end  of  twelve 
hours,  will  be  found  to  have  sunk  to  the  bottom  of  the  ves- 
sel. In  highly  concentrated  urine,  and  especially  in  that  of 
the  various  feverish  processes,  a  dense  cloud  of  urates  forms 
after  cooling  has  taken  place,  which,  as  well  as  the  other 
urinary  sediments,  will  be  considered  further  on  in  these 
pages. 

Odor, — Freshly-passed  normal  urine  has  a  faint  odor  pe- 
culiar to  itself,  which  gradually  disappears.  When  it  be- 
comes alkaline,  an  ammoniacal  odor  develops  itself  in  the 
urine.  When  blood  or  pus  becomes  added,  the  urine  has  a 
peculiarly  offensive  odor  from  its  rapid  decomposition. 

Turpentine,  when  inhaled  or  taken  internally,  imparts  an 
odor  of  sweet  violets  to  the  urine.  Copaiba,  cubebs,  tolu, 
and  asparagus,  also  communicate  a  characteristic  smell. 
Finally,  in  diabetes  mellitus,  the  urine  has  a  faint,  sweetish 
odor,  which,  if  acetonaemia  develops  itself,  comes  to  re- 
semble that  of  chloroform. 

Specific  Gravity. — The  specific  gravity  is  usually  and  most 
conveniently  estimated  by  means  of  a  urinometer.  The  in- 
strument is  dipped  into  the  urine  and  allowed  to  float,  the 
point  at  which  the  level  of  the  surface  of  the  urine  cuts  the 
graduated  stem  being  read  off,  and  thus  the  specific  gravity 
is  ascertained.  One  or  two  precautions,  must,  however,  be 
taken.  The  urinometer  must  be  carefully  dried  before  use, 
as  drops  of  water  adhering  to  the  upper  part  of  the  stem 
tend  unduly  to  depress  it.  It  must  also  float  completely 
clear  of  the  edge  of  the  vessel,  and  the  surface  of  the  urine 
must  be  free  from  air-bubbles,  which,  if  present,  can  be 
readily  removed  by  means  of  filter-paper.  As  urinometers 
are  graduated  for  a  temperature  corresponding  to  that  of 
an  ordinary  room,  observations  must  not  be  made  on  urines 
until  they  have  cooled  down  to  that  point. 

The  urinometer  scale  commences  at  1000,  the  specific 
gravity  of  distilled  water,  and  usually  goes  up  to  1050. 
The  average  specific  gravity  of  normal  urine  may  be  taken 
to  be  from  1015  to  1025;  but  readings  both  above  and  be- 


URINARY   SYSTEM.  I93 

low  these  limits  are  quite  consistent  with  perfect  health. 
The  specific  gravity  of  any  urine  expresses  of  course,  the 
quantity  of  solids  which  that  urine  contains  in  solution. 
Thus,  if  we  find  it  in  any  particular  instance  to  be,  let  us 
say,  1025,  we  know  that  there  are*  present  solids  in  such 
quantity  as  to  suffice  to  raise  the  weight  of  a  litre  of  dis- 
tilled water  from  1000  grammes  to  1025. 

From  the  specific  gravity  so  obtained,  it  is  possible  rough- 
ly to  calculate  the  quantity  of  solids  present  in  the  urine. 
This  may  be  done  by  means  of  the  very  simple  formula 
given  by  Trapp,  which  consists  in  multiplying  the  two  right 
hand  figures  by  two,  the  result  being  the  amount  of  the  sol- 
ids in  1000  parts  of  the  urine. 

From  what  has  been  said,  it  is  clear  that  as  the  specific 
gravity  of  the  urine  depends  upon  the  proportion  of  solids 
to  fluid,  it  will  be  affected  by  changes  in  the  quantity  of 
either.  Thus,  after  copious  imbibition  of  water,  the  urine 
of  healthy  persons  may  have  a  specific  gravity  as  low  as 
1002;  and,  on  the  contrary,  after  profuse  perspiration,  it 
may  rise  to  1040.  We  must  thus  take  into  account  the 
qua7itity  of  the  urine  passed  in  twenty-four  hours  before  we 
allow  ourselves  to  judge  what  importance  is  to  be  attached 
to  the  specific  gravity.  When  the  quantity  is  large,  we  find, 
if  the  urine  be  normal,  a  low  specific  gravity;  whereas, 
when  the  flow  is  scanty,  the  specific  gravity  is  high.  If, 
however,  we  meet  with  a  urine  which,  while  large  in  quan- 
tity, possesses  a  high  specific  gravity,  or  one  which,  while 
small  in  amount,  is  low  in  gravity,  then  the  fact  may  in 
each  case  be  noted  as  distinctly  pathological. 

Pathological  urines  may  be  classified  as  follows: 

High  Specific  Gravity  is  found  after  copious  perspiration, 
vomiting,  or  purging,  owing  to  the  consequent  concentra- 
tion of  the  urine.  At  the  commencement  of  all  acute  fever- 
ish diseases,  the  specific  gravity  of  the  urine  is  high,  running 
up  even  to  1035,  and  this  owing,  in  part,  to  diminished 
watery  excretion,  but  also,  in  great  measure,  to  the  in- 
increased  elimination  of  urea,  sulphates,  and  phosphates 
which  then  takes  place.  Much  more  marked  and  impor- 
tant, however,  is  the  increase  of  specific  gravity  met  with  in 
the  urine  of  diabetes  mellitus.  In  this  disease  we  find  large 
quantities  of  urine  being  passed,  the  specific  gravity  of 
which  varies  from  1030  to  1060,  its  height  being  due  to  the 
presence  of  grape  sugar. 

Low  Specific  Gravity^  when  not  dug  to  the  great  dilution 


194  MEDICAL  DIAGNOSIS. 

of  the  urine,  is  commonly  the  result,  either  of  some  disturb- 
ance the  secreting  apparatus  of  the  kidney  (Bright's  disease, 
circulatory  disease,  etc.),  or  of  general  interference  with 
nutrition  (anaemia,  cachexia,  etc.),  in  both  cases  arising  di- 
rectly from  the  defective  elimination  of  the  urinary  salts, 
particularly  urea  and  its  compounds. 

Keaction. — The  reaction  of  the  urine  may  be  tested  by 
means  of  blue  and  red  litmus  paper.  Normal  urine  is  acid 
when  fresh,  very  rarely  neutral  or  alkaline,  the  acidity  being 
due  to  the  presence  of  free  acids — such  as  lactic,  oxalic, 
hippuric,  and  acetic,  and  acid  salts.  After  a  meal,  the 
urine  loses  in  acidity,  sometimes  becoming  neutral  or  even 
alkaline;  but  it  very  rapidly  regains  its  former  character. 
The  effect  of  both  warm  and  cold  baths  is  to  render  the 
urine  alkaline;  and  the  same  result  is  produced  much  more 
powerfully  by  the  action  of  such  alkaline  medicines  as  the 
bicarbonates  and  acetates  of  potassium  and  sodium.  The 
effect  of  the  administration  of  acids  in  cases  of  alkaline 
urine  is  not  so  powerful;  but  by  means  of  carbonic  and 
benzoic  acids,  acidity  may  be  produced.  Alkalinity  of  the 
freshly-passed  urine  may  either  be  due  to  the  presence  of  a 
fixed  alkali*  (in  which  case  it  probably  results  from  some 
debilitating  influence  acting  upon  the  system  generally),  or 
to  the  presence  of  ammonia.  The  latter  form,  which  is  by 
far  the  most  common,  points  to  some  local  disease  in  the 
bladder  or  urethra.  Ammoniacal  urine  is  frequently  met 
with  in  cases  of  long-standing  urethral  stricture,  chronic  cys- 
titis, spinal  affections,  etc.  Highly  acid  urine,  on  the  other 
hand,  is  met  with  in  acute  febrile  diseases,  and  especially 
in  acute  rheumatism. 

Normal  urine  undergoes,  when  kept  too  long,  ferment- 
ative changes,  which,  as  they  are  liable  to  cause  mistakes, 
must  be  carefully  noted. 

I.  Acid  Fermentation. — If  the  urine  be  allowed  to  stand  ex- 
posed to  the  air,  in  a  cool  place,  it  will  be  found  that  its  re- 
action increases  in  acidity  steadily  from  day  to  day,  and 
may  continue  to  do  so  for  as  long  as  ten  days.  This  fer- 
mentation is  due   to   the   presence   of  a  peculiar  organism, 

*  If  the  alkalinity  be  due  to  the  presence  of  ammonia,  the  red  litmus 
paper,  which  has  been  turned  to  blue  by  dipping  in  the  urine,  will  regain 
its  red  tint  after  drying;  but  if  the  alkali  be  a  fixed  one,  the  blue  tint  will 
be  permanent. 


URINARY   SYSTEM.  I95 

resembling  yeast,  but  smaller,  and  is  accompanied  by  the 
precipitation  of  a  yellowish-brown  sediment  consisting  of 
uric  acid  and  urates,  and  frequently  of  oxalate  of  lime, 
along  with  clouds  of  mucus.  The  acidity  is  probably  due 
to  the  formation  of  lactic  and  acetic  acids. 

2.  Alkaline  Fermentation. — After  the  acid  reaction  has  fully 
developed  itself,  it  gradually  disappears,  and  the  urine  be- 
comes alkaline.  This  change  does  not  usually  set  in,  when 
the  urine  is  kept  cool,  before  eight  or  ten  days  have  passed; 
but  if  there  be  much  pus  or  mucus  present,  the  alkaline  re- 
action may  be  detected  much  sooner;  and  if  any  admixture 
of  old,  decomposed  urine  be  allowed  to  take  place  (as  from 
the  glass  not  having  been  thoroughly  cleaned),  it  may  come 
on  in  a  few  hours.  The  urine  now  becomes  lighter  in  color, 
opaque,  and  ammoniacal  in  odor,  the  urea  having  become 
changed  into  carbonate  of  ammonia.  A  white  sediment 
separates,  consisting  of  urate  of  ammonia,  triple  phosphate, 
amorphous  phosphates,  and  carbonate  of  lime. 


CHAPTER  XXIII. 

Urinary  System. — {continued). 

NORMAL    CONSTITUENTS    OF    URINE. 

The  normal  constituents  of  the  urine  may  be  divided  into 
two  classes — organic  and  inorganic.  Of  these  the  following, 
which  are  the  most  important,  will  be  here  considered: 

Organic  Substances. — i.  Urea;  2.  Uric  Acid.;  3.  Creatinin; 
4.  Indican. 

Inorganic  Substances. — i.  Chlorides;  2.  Sulphates;  3.  Phos- 
phates. 

Urea  is  by  far  the  most  important  constituent  of  normal 
urine,  and  it  is  to  be  regarded  as  the  chief  product  of  the 
decomposition  of  albumen,  and  the  last  product  of  the  re- 
gressive metamorphosis  of  the  nitrogenous  tissues  of  the 
body.  The  quantitative  estimation  of  urea  is  therefore  of 
much  importance.  It  may  be  carried  out  in  either  of  two 
ways, 

(i.)  Estimation  of  Urea  by  means  of  Nitrate  of  Mercury. — • 


196  MEDICAL  DIAGNOSIS. 

This  method,  which  was  first  introduced  by  Liebig,  depends 
the  property  which  urea  possesses  of  forming  an  insoluble 
compound  with  nitrate  of  mercury.  When,  a  dilute  solution 
of  the  mercury  salt  is  added  to  a  solution  of  urea,  this  pre- 
cipitate forms  so  long  as  any  urea  remains  unaltered.  If, 
however,  more  nitrate  of  mercury  be  added  when  no  more 
urea  is  present,  a  drop  of  the  mixture  when  added  to  a  so- 
lution of  carbonate  of  soda  gives  a  yellow  precipitate  of  the 
hydrated  oxide  of  mercury.  In  this  way  can  be  determined 
the  exact  point  at  which  all  the  urea  has  been  decomposed. 
Before  this  method  can  be  applied,  however,  the  phosphates 
and  sulphates  which  the  urine  contains  must  be  precipi- 
tated by  means  of  a  solution  of  baryta.  For  the  volu- 
metric analysis  of  urea  we  therefore  require  three  solu- 
tions. 

1.  A  solution  of  7iitrate  of  merctL7-y^  of  which   i  cub.  centi- 

metre corresponds  to  o.oi  gramme  of  urea.  The 
method  of  preparation  will  be  described  in  Appen- 
dix B. 

2.  A  solution  of  baryta,  prepared  by  mixing  one  volume 

of  a  cold  saturated  solution  of  nitrate  of  baryta  with 
two  volumes  of  cold  saturated  baryta  water. 

3.  A  solution  of  carbonate  of  soda  of  about  twenty  grains 

to  the  ounce. 
The  urine  must  first  be  freed  from  phosphates  and  sul- 
phates, and  for  this  purpose  40  c.c.  are  measured  off  by 
means  of  a  pipette,  and  20  c.c.  of  the  baryta  mixture  added. 
After  filtration,  15  c.c.  of  the  filtrate  (corresponding  to  10 
c.q.  of  the  original  urine)  are  measured  oft"  into  a  small 
beaker,  which  is  placed  under  a  graduated  burette  contain- 
ing the  standard  solution  of  nitrate  of  mercury.  From  this 
burette  small  quantities  of  the  solution  are  successively 
added  to  the  urine,  the  mixture  being  all  the  time  carefully 
stirred  by  means  of  a  glass  rod,  and  the  additions  are  to  be 
cautiously  continued  so  long  as  a  distinct  precipitation  fol- 
lows each  drop.  When,  however,  the  formation  of  the  in- 
soluble compound  appears  to  be  getting  less  distinct,  and 
the  analysis  consequently  approaches  completion,  a  drop  of 
the  mixture  must  be  removed  on  the  stirring  rod  and  added 
to  a  small  quantity  of  the  solution  of  carbonate  of  soda, 
which  has  been  placed  on  a  porcelain  plate,  or  better,  in  a 
watch-glass  with  a  black  background.  Should  a  white 
precipitate  form,  the  addition  of  mercury  must  be  con- 
tinued, but  as  soon  as  a  yellow  color  appears  when  a  drop 


urinarv  system.  197 

is  added  to  the  soda  solution,  the  analysis  is  at  an  end. 
The  quantity  of  the  nitrate  of  mercury  solution  which  has 
been  used  is  now  to  be  read  off,  and  a  calculation  made,  re- 
membering that  every  cubic  centimetre  corresponds  to  o.oi 
gramme  of  urea.  Corrections  are,  however,  under  certain 
circumstances,  necessary.  If,  in  the  course  of  the  analysis, 
it  be  found  that  more  than  30  c.c.  of  the  mercury  solution 
are  being  used  for  15  c.c.  of  the  urine  mixture,  we  must 
add  to  the  urine,  before  applying  the  carbonate  of  soda 
test,  half  the  number  of  cubic  centimetres  of  water  as  we 
have  used  of  mercury  solution  above  30.  Thus,  if  48  c.c, 
of  the  standard  solution  have  been  dropped  in,  we  should 
have  to  add  9  c.c.  of  water  before  we  transferred  a  drop  to 
the  carbonate  of  soda  solution.  On  the  other  hand,  if  less 
than  30  c.c.  of  the  mercury  solution  have  sufficed  to  precip- 
itate all  the  urea,  we  must  subtract  from  the  total  sum  of  the 
mercury  solution  used  o.  i  c.c.  for  every  5  c.c.  less  than  30. 
For  example,  if  only  20  c.c.  of  the  standard  solution  have 
been  used,  we  must  substract  0.2,  leaving  19.8  as  the  sum 
from  which  we  have  to  calculate.  If  great  accuracy  be  re- 
quired, the  chlorides  should  be  previously  removed  by  pre- 
cipitation wath  nitrate  of  silver.  The  modifications  in  this 
method  which  have  been  recently  suggested  by  Pfiiiger* 
are  too  complicated  to  be  described  here. 

(2.)  The  Estimation  of  Ui'ea  by  mea?is  of  Hypobromite  of 
Soda. — In  principle  this  method  was  first  described  by 
Davy.  It  depends  upon  the  fact  that  urea,  when  treated 
with  hypobromite  of  soda,  breaks  up  into  nitrogen,  water, 
and  carbonic  acid,  the  last  of  which  is  absorbed  in  the  al- 
kaline solution,  while  the  nitrogen  comes  off  as  free  gas. 
Of  the  many  forms  of  apparatus  which  have  been  described 
and  are  used  for  this  analysis,  perhaps  the  most  simple  is 
that  of  Dr.  Graham  Steele. f  It  consists  of  an  ordinary 
burette  inverted  in  a  tall  glass  cylinder  containing  water, 
and  connected  with  a  small  conical  glass  vessel  containing 
a  short  test-tube.  After  removing  the  test-tube,  the  coni- 
cal vessel  is  filled  to  the  depth  of  about  an  inch  with  the 
solution  of  hypobromite  of  soda  (the  method  of  preparing 
which  will  be  presently  described),  and  into  this  the  test- 
tube  is  carefully  slipped,  after  5  c.c.  of  the  urine  to  be 
tested  have  been  placed  in  it.     The  cork  of  the  conical  ves- 

*  Arch.  f.  d.  ges.  Physiol.,  xxi.  and  xxiii. 
f  Edin.  Med.  fournal,  1 8 74. 


iqS  medical  diagnosis. 

sel  is  then  replaced,  and  the  vessel  dipped  into  water.  The 
burette,  which  is  now  in  communication  with  the  conical  ves- 
sel, is  next  raised  or  lowered  as  may  be  required,  until  the 
level  of  the  water  inside  and  outside  is  the  same,  and  this 
point  is  read  off.  The  conical  vessel  is  now  tilted  over  so  as 
to  allow  the  urine  in  the  test-tube  to  flow  out  and  to  become 
mixed  with  the  hypobromite  solution.  This  mixture  is  fol- 
lowed by  a  rapid  giving  off  of  gas,  and  after  all  efferves- 
cence has  ceased,  and  the  nitrogen  which  has  collected  in 
the  burette  has  had  time  to  cool  down  to  the  temperature 
of  the  room,  the  burette  is  again  moved  so  as  to  bring  the 
water-level  inside  to  the  same  height  as  that  outside,  and 
this  point  read  off.  The  difference  of  the  two  readings 
gives  the  quantity  of  nitrogen  which  has  been  given  off. 
Since  we  know  that  at  the  ordinary  temperature  of  a  room, 
O.I  gramme  of  urea  gives  off  37.5  c.c.  of  nitrogen,  the  cal- 
culation is  simple.  This  method,  from  the  ease  with  which 
it  can  be  carried  out,  is  very  convenient,  but  it  is  not  ex- 
tremely accurate,  for  not  only  urea,  but  also  uric  acid  and 
creatinin,  give  off  nitrogen  when  treated  with  hypobromite 
of  soda.  The  error  is,  however,  small.  The  preparation 
of  the  solution  of  hypobromite  of  soda  is  made  as  follows: 
100  grammes  of  caustic  soda  are  dissolved  in  water,  and 
the  solution  diluted  to  1250  c.c.  To  this  25  c.c.  of  bromine 
are  to  be  added,  and  the  whole  shaken  vigorously.  This 
solution  must  be  kept  in  a  stoppered  bottle  and  in  the 
dark.  It  decomposes  rapidly,  and  can  only  be  used  when 
freshly  prepared. 

The  quantity  of  urea  excreted  in  twenty-four  hours  in 
healthy  men  averages  from  300  to  500  grains.  It  is  in- 
creased after  exertion,  and  after  a  full  meal  of  animal 
food.  In  almost  all  diseases  attended  with  elevation  of 
temperature,  the  urea  elimination  is  increased.  Thus  in  ty- 
phus, pneumonia,  pleurisy,  and  acute  rheumatism,  the 
amount  of  urea  excreted  is  usually  much  above  normal.  In 
diabetes  mellitus,  I  have  seen  the  daily  quantity  to  be  as 
high  as  1800  grains.  This  is  no  doubt  in  part  due  to  the 
large  quantity  of  animal  food  consumed  in  this  disease. 
On  the  other  hand,  the  urea  is  diminished  in  almost  all  af- 
fections of  the  kidney,  owing  to  defective  eliminating  pow- 
er of  that  organ.  Particularly  is  this  the  case  with  regard 
to  acute  inflammatory  Bright's  disease,  and  to  the  cirrhotic 
or  contracting  form,  especially  when  in  its  later  stages  a 
degree  of  inflammatory  action  becomes  superadded. 


URINARY   SYSTEM.  I99 

The  urea  excretion  is  affected  by  the  administration  of 
drugs,  but  much  uncertainty  exists  as  to  the  action  of 
many  of  these.  Phosphorus  undoubtedly  increases  the 
elimination  of  urea,  as  do  also  most,  if  not  all,  diuretics. 
Morphia,  quinine,  and  iodide  of  potassium,  on  the  contrary, 
tend  to  diminish  its  qyantity. 

Uric  Acid  exists  in  normal  urine  in  combination  with 
potassium,  sodium,  ammonium,  calcium,  or  magnesium  ; 
and,  as  all  these  salts  of  uric  acid  are  very  much  more  sol- 
uable  in  hot  than  in  cold  urine,  they  tend  to  separate  out 
as  the  urine  cools.  The  cloud  of  urates  which  thus  so  often 
appears  soon  after  the  urine  is  passed  may  be  readily  recog* 
nized  by  warming  a  small  quantity  of  the  urine  containing 
the  sediment  in  a  test-tube,  when  it  rapidly  becomes  clear. 
Uric  acid  is  readily  separated  from  urine  by  adding  hydro- 
chloric adid.  It  then  deposits  itself  in  crystalline  form,  the 
character  of  which  will  be  described  when  we  come  to  speak 
of  urinary  sediments. 

Detection  of  Uric  Acid. — It  is  often  important  to  be  able 
to  detect  the  presence  of  uric  acid  in  concretions  and  sedi« 
ments.  Very  frequently  this  may  be  done  by  means  of  the 
microscope,  but  this  is  not  always  possible.  Uric  acid  can 
however  always  be  detected  by  means  of  the  mu7'exid  test, 
which  is  applied  as  follows  :  A  small  quantity  of  the  sedi- 
ment is  dissolved  in  a  porcelain  dish  with  a  few  drops  of 
nitric  acid,  and  the  solution  so  obtained  is  evaporated.  To 
the  reddish  residue  one  or  two  drops  of  dilute  ammonia 
are  added,  when  the  beautiful  reddish  purple  color  of  mu- 
rexid  develops  itself,  which,  on  the  further  addition  of  a 
few  drops  of  caustic  potash,  passes  into  bluish  purple. 

The  quantitative  estimation  of  uric  acid  is  difficult  to  carry 
out.  A  large  quantity  of  urine  (100-200  c.c.)  is  taken,  and 
to  it  is  added  5  c.c.  of  pure  hydrochloric  acid.  The  mixture 
is  allowed  to  stand  for  forty-eight  hours,  and  the  precipi- 
tate of  uric  acid  is  then  collected  on  a  filter,  washed  with  a 
little  cold  water,  and  weighed.  Salkowski  has  however 
recently  pointed  out^  that  by  no  means  all  the  uric  acid 
which  the  urine  contains  is  thus  removed  by  precipitation, 
and  that  the  proportion  which  remains  varies  much  in 
different  urines.  He  recommends  that  the  filtrate  should 
be  further  treated  with  ammonia  and  magnesia,  and  after 

*  Virchow's  Archiv.,  vol.  Hi. 


200  MEDICAL  DIAGNOSIS. 

the  precipitate  of  phosphates  has  been  removed  by  rapid 
filtration,  that  the  filtrate  should  be  further  treated  with  an 
ammoniacal  silver  solution.  The  precipitate  which  is  thus 
formed,  after  careful  washing,  is  then  decomposed  with  sul- 
phuretted hydrogen,  the  filtrate  acidulated  with  hydro- 
chloric acid,  and  the  uric  acid  which  then  separates  out 
collected  and  weighed. 

The  average  quantity  of  uric  acid  excreted  in  twenty-four 
hours  is  about  0.5  to  i  gramme.  It  rises  and  falls  simul- 
taneously with  urea,  bearing  the  relation  to  that  substance 
of  I  to  50  or  60  in  the  healthy  state.  It  is  much  increased 
by  an  animal  diet.  In  most  feverish  conditions  the  excre- 
tion of  uric  acid  corresponds  with  that  of  urea,  but  when  the 
respiration  is  interfered  with,  Bartels  states  that  it  is  in- 
creased. During  an  attack  of  gout  the  excretion  is  dimin- 
ished, but  after  the  paroxysm  is  over,  it  undergoes  some 
increase.  It  is  increased  in  many  hepatic  affections,  in 
leucocythaemia,  in  acute  rheumatism,  and  sometimes  in  cases 
of  simple  indigestion.  The  appearance  of  a  sediment  of 
uric  acid  is  only  to  be  looked  upon  as  pathological  when  it 
occurs  either  before  the  urine  cools  or  immediately  there- 
after. 

Creatinin  is  a  normal  constituent  of  urine,  and  is  present 
in  somewhat  larger  quantity  than  uric  acid.  Its  presence  is 
readily  detected  by  adding  to  a  small  quantity  of  urine  a 
few  drops  of  a  very  dilute  solution  of  nitro-prusside  of 
sodium,  when,  on  the  further  addition  of  dilute  caustic  soda 
a  beautiful  ruby  red  color  develops  itself,  which  soon  passes 
into  deep  straw  yellow. 

Quantitative  Analysis  of  Creatinin. — 300  c.c.  of  urine  are 
taken,  rendered  alkaline  by  the  addition  of  milk  of  lime, 
and  then  decomposed  with  chloride  of  lime  until  no  more 
precipitation  takes  places.  The  filtrate  is  rapidly  evaporated 
to  the  consistence  of  syrup,  and  mixed  with  50  c.c.  of  al- 
cohol (95  per  cent.).  The  mixture  is  allowed  to  stand  until 
all  the  chloride  of  sodium  has  separated  out,  is  then  fil- 
tered, and  the  filtrate  evaporated  down  and  treated  with  an 
alcoholic  solution  of  chloride  of  zinc.  After  standing  for 
three  days,  the  zinc-creatinin  chloride  will  have  become 
fully  separated,  and  may  then  be  collected  on  a  filter  and 
weighed. 

The  quantity  of  creatinin  excreted,  which  is  normally 
about  one   gramme  ^er  diem,  is  increased    in  typhus  and 


URINARY   SYSTEM.  201 

pneumonia,  and  diminished  in  anaemia,  chlorosis,  and  tuber- 
culosis. 


Indican. — It  is  not  uncommon  to  encounter  dark-yellow 
urines,  in  which,  on  the  addition  of  nitric  acid,  there  be- 
comes developed  the.  dark  violet  color  of  indigo.  The 
original  pigment  which  is  thus  decomposed  was  first  studied 
by  Schunck,*  who  took  it  to  be  identical  with  the  indican 
of  plants.  Later  investigations  have  however  shown  that 
the  two  substances  are  not  quite  identical,  and  that  the  in- 
dican found  in  urine  is  to  be  looked  upon  as  'potassium- 
indoxyl-sulphate.  It  is  identical  with  the  uroxanthin  of 
Heller.  Indican,  when  treated  with  a  mineral  acid,  yields 
indigo,  and  this  decomposition  often  takes  place  in  the  urine 
spontaneously  after  decomposition  has  set  in,  the  indigo 
appearing  on  the  edge  of  the  glass  and  on  the  surface  of 
the  urine  as  a  glistening  dark-blue  film.  Indican  is  a  deriva- 
tive from  indol,  which  is  a  result  of  the  changes  which  al- 
bumen undergoes  in  the  intestines,  and  Jaffe  was  the  first  to 
point  outf  what  was  subsequently  confirmed  by  Baumann 
and  others,  that  when  indol  was  injected  subcutaneously 
in  animals  indican  appeared  in  quantity  in  the  urine. 

Detection  of  Iiidican. — The  original  process  of  Jaffe  as 
modified  by  Senator  J  is  as  follows:  In  a  large  test-tube 
are  placed  10-15  c.c.  of  the  urine,  and  to  this  is  added  an 
equal  quantity  of  fuming  hydrochloric  acid,  and  then  a 
concentrated  solution  of  chloride  of  lime  drop  by  drop,  un- 
til the  blue  color  is  fully  developed.  The  mixture  is  now 
to  be  shaken  up  with  chloroform,  after  which  the  chloro- 
form will  sink  to  the  bottom,  more  or  less  deeply  tinged  with 
indigo.  By  this  means  a  rough  idea  of  the  quantity  of  in- 
dican present  may  also  be  arrived  at. 

The  method  of  estimating  accurately  the  quantity  of 
indican  as  given  by  Jaffe, §  is  very  complicated,  and  for  its 
details  the  original  must  be  consulted. 

The  quantity  of  indican  contained  in  human  urine  aver- 
ages 6.6  mgrm.  in  1000  c.c.  In  disease  the  indican  excretion 
has  been    frequently   investigated,  most  fully  perhaps  by 


*  Proceedings  of  the  Royal  Society,  1857. 
f   Centralbl.  f.  d.  med.,   Wiss,  1872. 
X  Ibid.  1877,  p  357. 
§  Pfliiger's  Archiv.,  iii. 


202  MEDICAL   DIAGNOSIS. 

Hennige.*  The  most  important  clinical  point  is  that  in- 
dican  appears  in  large  quantity  in  the  urine  when  there  is 
obstruction  of  the  small  intestine,  while,  when  the  obstruc- 
tion is  seated  in  the  large  intestine,  no  such  augmentation 
takes  place.  In  cases  of  ileus,  therefore,  when  the  exact 
seat  of  the  disease  is  doubtful,  the  estimation  of  the  indican 
in  the  urine  may  have  considerable  diagnostic  value. 

Passing  now  to  the  consideration  of  the  inorganic  sub- 
stances which  are  found  in  normal  urine,  we  come  first  to 
the 

Chlorides. — The  chlorine  which  is  contained  in  urine  exists 
in  combination  with  potassium,  sodium,  ammonium,  mag- 
nesium, or  calcium.  The  presence  of  these  chlorides  may 
be  detected  by  adding  to  a  small  quantity  of  urine  in  a 
test-tube  a  few  drops  of  nitric  acid,  and  then  a  small  quan- 
tity of  a  solution  of  nitrate  of  silver.  A  white  flocculent 
precipitate  at  once  falls,  consisting  mainly  of  chloride  of 
silver,  but  also  containing  combinations  of  silver  with  uric 
acid,  creatinin,  xanthin,  and  urinary  pigments. 

Estijnation  of  the  Chlorides. — Mohr's  method  depends  upon 
the  fact  that  when  to  a  neutral  urine  containing  chloride 
and  phosphate  of  sodium  and  a  neutral  salt  of  chromic 
acid,  a  solution  of  nitrate  of  silver  is  added,  there  first  oc- 
curs a  precipitation  of  chloride  of  silver;  and  when  the 
point  is  reached  when  all  the  chlorine  contained  in  the 
chloride  of  sodium  is  so  precipitated,  there  then  begins  the 
precipitation  of  the  red  chromate  of  silver.  For  this  analy- 
sis we  therefore  require — 

1.  A  solution  of  nitrate  of  silver,  of  which  i   c.c.  corre- 

sponds to  ID  milligrammes  of  chloride  of  sodium 
or  to  6.065  milligrammes  of  chlorine. 

2.  A  cold  saturated  solution  of  neutral  chromate  of  potas- 

sium. 

3.  Pure  nitrate  of  potassium. 

4.  Ptire  carbonate  of  lime. 

Since  the  presence  of  urinary  pigments  prevents  the  ac- 
curacy of  this  method,  the  silver  combining  with  them, 
they  must  first  be  got  rid  of  in  the  following  manner: 

10  c.c.  of  urine  are  mixed  with  2  grammes  of  nitrate  of 
potassium  in  a  platinum  capsule,  evaporated    to    dryness 

*  Deutsches  Archiv.  f.  kl.  med.,  xxlii.,  p.  271. 


URINARY   SYSTEM.  203 

and  finally  heated  in  a  naked  flame  until  the  carbon  is  com- 
pletely oxidized.  The  residue  is  then  dissolved  in  water  in 
a  beaker,  acidulated  with  a  dilute  solution  of  pure  nitric 
acid,  and  then  neutralized  with  a  little  carbonate  of  lime. 
To  the  fluid  so  obtained,  which  need  not  be  filtered,  four 
or  five  drops  of  the  chromate  solution  are  added,  and  then 
the  silver  solution  is  gradually  dropped  into  it  from  a 
burette,  the  mixture  being  constantly  stirred.  Reddish 
spots  appear  where  the  solution  falls,  but  they  disappear 
on  stirring,  so  long  as  any  chloride  of  sodium  is  present. 
So  soon,  however,  as  the  whole  of  that  salt  is  decomposed, 
the  next  drop  of  the  silver  solution  gives  rise  to  a  perma- 
nent red  which  marks  the  conclusion  of  the  operation. 
The  amount  of  the  silver  solution  which  has  been  used  is 
now  read  off,  and  as  we  know  that  each  cubic  centimetre 
corresponds  to  6.065  milligrammes  of  chlorine,  the  calcula- 
tion is  easy. 

The  average  quantity  of  chlorine  excreted  in  the  urine 
in  twenty-four  hours  may  be  taken  to  be  in  the  healthy 
state  about  10  or  12  grammes.  It  is  increased  by  the  con- 
sumption of  a  greater  quantity  of  common  salt,  and  by  the 
copious  drinking  of  water. 

In  disease  the  most  important  change  which  occurs  in 
the  elimination  of  the  chlorides  is  the  remarkable  diminu- 
tion met  with  in  acute  feverish  conditions,  particularly  in 
pneumonia.  As  the  result  of  a  very  interesting  series  of 
observations,  Rohmann  ^  comes  to  the  conclusion  that  this 
diminution  is  due,  not  to  a  decrease  in  the  amount  of 
chlorine  taken  along  with  the  food,  but  to  a  change  in  the 
relation  of  the  albumen  of  the  blood  to  the  chloride  of 
sodium  in  the  plasma. 

Sulphates. — The  sulphates  which  are  found  in  the  urine 
are  derived  from  the  breaking  up  of  albumen,  either  that 
of  the  tissues  or  that  which  is  contained  in  the  food.  Sul- 
phuric acid  exists  in  the  urine  in  two  forms — first,  in  com- 
bination with  the  alkalies;  and,  second,  as  Baumann  has 
shown,  in  the  form  of  arornatic  ether-sulphuric  acid — chiefly 
phenyl-sulphuric  acid  and  indoxyl-sulphuric  acid.  Both 
of  these  aromatic  bodies  when  heated  with  hydrochloric 
acid  break  up  into  phenol  or  indigo  and  sulphuric  acid. 
Acetic  acid  does  not  cause  this  decomposition. 


*  Zeitschrift.  f.  kl.  nied.,  vol.  i.,  p.  513. 


204  MEDICAL  DIAGNOSIS. 

Detectio7t  of  the  Sulphates. — Acidulate  strongly  with  acetic 
acid,  and  on  tlie  addition  of  chloride  of  barium  a  white 
precipitate  of  sulphate  of  barium  will  fall,  representing  the 
sulphuric  acid  which  was  combined  with  the  alkalies.  If 
now  the  mixture  be  filtered  and  heated  with  hydrochloric 
acid,  ^  further  precipitate  of  sulphate  of  barium  will  fall, 
representing  in  this  case  the  ether-sulphuric  acid. 

Estimatio7i  of  the  Sulphates. — If  these  two  precipitates  which 
have  just  been  mentioned  be  weighed,  the  total  amount  of 
the  sulphates,  as  well  as  that  of  each  form,  may  be  calcu- 
lated. Fiirbinger^  has  pointed  out  an  easy  manner  of  ob- 
taining results  which  are  approximately  accurate,  and  quite 
sufficiently  so  for  comparative  observations,  which  is  to 
wash  the  precipitates  in  question  into  a  very  narrow  grad- 
uated cylindrical  vessel,  and  allow  them  to  settle  down. 
After  some  hours  their  upper  level  may  be  read  off,  and  if 
the  physician  possesses  the  result  of  only  one  weighing  of 
such  a  precipitate,  he  can  always  translate  into  weight  the 
height  of  his  precipitates.  For  the  purpose  of  such  an 
analysis,  however,  at  least  300  c.c.  of  urine  must  be  taken.    ' 

The  normal  quantity  of  sulphuric  acid  which  is  excreted 
in  the  urine  in  twenty-four  hours  is  about  two  grammes. 
It  is  increased  and  diminished  according  as  more  or  less 
albumen  is  broken  up,  and  therefore  it  corresponds  with 
the  quantity  of  urea  and  uric  acid,  both  in  health  and  in 
disease. 

Sulphur  is  also  excreted  in  the  urine  in  small  quantity  in 
the  form  of  sulphocyanic  acid,  of  taurin,f  and  occasionally 
of  cystin.  Sulphuretted-hydrogen  is  also  sometimes  met 
with  in  the  urine  in  disease. 

Phosphates. — In  normal  acid  urine  phosphoric  acid  is  met 
with  in  the  form  of  the  phosphates  of  the  alkalies,  sodium 
and  potassium,  and  of  calcium  and  magnesium.  It  may 
also  appear  in  the  form  of  glycerin-phosphoric  acid  and 
lecithin.  It  is  derived  in  part  from  the  food,  and  in  part 
from  the  breaking  down  of  tissues  of  the  body  which  con- 
tain phosphorus,  principally  the,  osseous  and  the  nervous 
structures. 

When  the  urine  loses  its  carbonic  acid,  as  it  does  when 
heated,  the  earthy  phosphates  separate  out  as  a  white  floc- 

*  Virchow's  y^rc^z'z/.,  vol.  Ixxiii. 

f  Salkowski-Virchow's  y5fr<:/^^z/.,  vol.  Iviii. 


URINARY    SYSTEM.  205 

culent  precipitate,  which  becomes  redissolved  on  the  addi- 
tion of  acid.  The  addition  of  ammonia  to  urine  causes  an 
amorphous  precipitate  of  phosphate  of  lime,  while  the 
phosphate  of  magnesium  unites  with  the  ammonia  to  form 
ammonio-magnesian  phosphate  (triple-phosphate),  which 
appears  in  a  crystalline  form.  The  microscopic  appearance 
of  all  the  various  forms  of  phosphate  will  be  described 
when  we  come  to  speak  of  urinary  sediments. 

Estimation  of  Phosphoric  Acid. — The  principle  of  Neu- 
bauer's  method  is  the  following:  When  a  hot  solution  of 
the  phosphates  in  question  is  acidulated  with  acetic  acid, 
it  gives,  with  a  solution  of  acetate  of  uranium,  a  precipitate 
of  uranium  phosphate.  The  point  at  which  this  reaction 
ends  is,  from  the  nature  of  the  precipitate,  difficult  to  de- 
termine, and  it  is  consequently  necessary  to  test  the  mix- 
ture from  time  to  time  with  a  solution  of  ferro-cyanide  of 
potassium,  which  gives,  w^hen  there  is  present  the  slightest 
excess  of  the  uranium  solution,  a  dark  reddish-brown  color- 
ation.    The  solutions  required  are: 

1.  A  solution  of  uranic  oxide  of  which  i  c.c.  is  equivalent 

to  0.005  gramme  of  phosphoric  acid,  PoO.. 

2.  A  solution   of  acetate  of  soda  prepared  by  dissolving 

100  grammes  of  that  salt  in  900  c.c.  of  water,  and  ad- 
ding 100  c.c.  of  concentrated  acetic  acid. 

3.  A  solution  of  ferro-cyanide  of  potassium  not  too  con- 
centrated. 

To  50  c.c,  of  the  urine  are  added  5  c.c.  of  soda  solution, 
and  the  mixture  is  placed  in  a  beaker  glass,  and  warmed 
in  a  sand  bath.  From  a  burette  the  uranium  solution  is 
gradually  added  to  the  urine,  until  no  further  precipitation 
appears  to  take  place.  A  drop  is  now  removed,  placed  on 
a  porcelain  slab  and  mixed  with  a  drop  of  the  solution  of 
ferro-cyanide  of  potassium.  If  there  be  any  excess  of 
uranium — i.e.,  if  the  analysis  be  at  an  end — a  reddish- 
brown  precipitate  will  appear  where  the  drops  come  in  con- 
tact. If  this  reaction  does  not  take  place,  more  uranium 
solution  must  be  added  to  the  urine.  Each  cubic  centi- 
metre of  the  uranium  solution  used  corresponds  to  0.005 
gramme  of  phosphoric  acid,  so  that  the  calculation  is  easy. 

If  it  is  wished  to  estimate  separately  the  earthy  phos- 
phates, these  must  be  precipitated  by  the  addition  of  am- 
monia,   the   precipitate  carefully   separated   by    filtration, 


206  MEDICAL   DIAGNOSIS. 

dissolved  in  water  with  the  addition  of  a  little  acetic  acid, 
and  the  solution  treated  in  the  manner  just  described. 

The  average  quantity  of  phosphoric  acid  which  is  ex- 
creted in  the  urine  in  twenty-four  hours  is  in  the  adult 
about  three  grammes,  two  thirds  of  which  may  be  taken  to 
consist  of  the  phosphates  of  the  alkalies,  and  one  third  of 
earthy  phosphates.  The  quantity  depends  to  a  large  ex- 
tent upon  the  food — animal  diet  giving  rise  to  more  excre- 
tion than  vegetable — and  upon  the  condition  of  the  alvine 
secretion,  the  earthy  phosphates  in  particular  being  much 
increased  in  quantity  when  there  is  much  constipation. 
Tissue  change  also  influences  the  phosphatic  elimination  to 
a  large  extent,  chiefly  that  which  takes  place  in  the  nervous 
structures. 

In  the  feverish  state  the  phosphates  are  at  first  dimin- 
ished, but  when  convalescence  sets  in  their  amount  in  the 
urine  is  increased  to  a  point  above  normal.  In  chronic 
nervous  diseases  the  phosphates  are  usually  present  to  an 
excessive  amount  in  the  urine,  and  in  ostiomalacia  the  earthy 
phosphates  are  increased  to  such  a  degree  that  they  may  be 
found  to  be  in  excess  of  the  phosphates  of  the  alkalies.  In 
meningitis  also  the  phosphates  have  been  found  to  be  in- 
creased, and  this  fact  is  often  useful  in  the  differential  diag- 
nosis of  that  complaint. 


CHAPTER  XXIV. 

Urinary  System — {continued). 

ABNORMAL    CONSTITUENTS    OF    URINE. 

The  substances  which  are  commonly  grouped  under  this 
heading  are  some  of  them  present  in  normal  urine,  as,  for 
example,  sugar  and  oxalic  acid  ;  but  their  quantity  is  then 
so  small  as  to  elude  detection  by  the  ordinary  methods  of 
analysis,  and  it  is  only  under  pathological  conditions  that 
they  appear  in  sufficient  quantity  to  require  notice.  Other 
members  of  this  group  are,  however,  never  present  in  nor- 
mal urine. 

Albumen. — The  presence  of  albumen  in  the  urine  is  one 
of   the   most   important   diagnostic  indications  which  the 


URINARY    SYSTEM.-  20/ 

physician  can  encounter.  The  special  circumstances  under 
which  albuminuria  occurs  will  be  detailed  presently.  In 
the  meantime  we  have  to  consider  the  methods  by  means 
of  which  its  presence  may  be  detected,  and  its  quantity  es- 
timated. 

The  chief  albuminous  substances  which  appear  in  the 
urine  are — 

1.  Serum-albumen. 

2.  Serum-globulin  (paraglobulin). 

3.  Propepton. 

4.  Fibrin. 

The  first  two  of  these  substances  are  both  detected  by 
the  ordinary  tests  for  albumen.  Their  separation  will  be 
subsequently  considered. 

Detection  of  Albumen  (serum-albumen  and  serum-globu- 
lin).— Before  testing  for  albumen,  the  urine  in  question  must, 
if  not  already  clear,  be  rendered  so  by  careful  filtration. 
Of  the  many  methods  employed,  the  following  are  the  most 
important  : 

(i.)  Boiling  Test. — If  a  small  quantity  of  urine  be  placed 
in  a  test-tube,  and  heated  in  the  flame  of  a  spirit-lamp  or 
Bunsen  burner,  it  will  be  found  that  when  the  temperature 
has  risen  to  near  the  boiling  point  the  albumen,  if  present, 
separates  out  as  a  white  cloud,  which,  on  standing,  collects 
at  the  bottom  of  the  tube  in  fine  flakes.  If  the  urine  con- 
tain much  earthy  phosphates,  these  are  apt  to  separate 
when  the  tube  is  heated,  and  the  cloud  so  formed  may  be 
mistaken  for  albumen.  It  is,  however,  dissolved  on  the 
addition  of  a  few  drops  of  acetic  acid.  If  the  urine  be  al- 
kaline to  begin  with,  the  albumen  may  not  be  separated 
out  on  boiling.  It  is  therefore  necessary  to  acidulate  with 
a  few  drops  of  acetic  acid  ;  but  inasmuch  as  there  is  some 
risk  of  adding  too  much  of  this  acid,  and  so  preventing  the 
albumen  reaction  from  taking  place,  it  is  best  to  proceed  in 
all  cases  as  follows  : 

5-10  c.c.  of  urine  are  placed  in  a  test-tube  acidulated  with 
acetic  acid,  and  1-6  of  its  volume  of  a  concentrated  solution 
of  sulphate  of  magnesia  added.  If  albumen  be  present, 
there  will  now  appear  on  heating  a  more  or  less  distinct 
cloudiness.  This  test  is  absolutely  trustworthy,  and  in 
point  of  delicacy  is  probably  surpassed  by  none. 

(2.)  Nitric  Acid  Test. — A  small  conical  glass  is  taken  and 
filled  about  one  third  full  of  urine.     Down  its   side,  while 


208  MEDICAL  DIAGNOSIS. 

it  is  held  inclined,  are  poured  slowly  a  few  drops  of  strong 
nitric  acid,  in  such  a  way  that  when  the  glass  is  again  held 
in  an  upright  position,  the  acid  forms  a  distinct  layer  at 
the  bottom.  If  albumen  be  present  in  the  urine,  a  cloud 
will  form  at  the  line  of  junction  of  the  two  fluids. 

If  the  urine  contain  a  large  quantity  of  neutral  urate  of 
sodium  or  ammonium,  the  addition  of  nitric  acid  may 
cause  the  separation  of  the  acid  urates  in  the  form  of  a 
cloud.  This  cloud  lies  near  the  upper  surface  of  the  urine, 
and  is  therefore  not  readily  mistaken  for  albumen  ;  but  in 
cases  of  doubt  it  is  only  necessary  to  warm  the  glass,  and  so 
cause  solution  of  the  cloud,  or  to  dilute  the  urine  previously 
with  twice  or  thrice  its  volume  of  water,  after  which  no  such 
cloud  will  form. 

(3.)  The  Ferrocyanide  Test. — To  the  urine  contained  in  a 
test-tube  a  drop  or  two  of  acetic  acid  is  to  be  added,  and 
then  a  small  quantity  of  a  solution  of  ferrocyanide  of  potas- 
sium. If  albumen  be  present,  a  white  flocculent  precipitate 
will  separate  out  in  the  cold. 

Other  tests,  such  as  those  in  which  carbolic,  tannic,  and 
metaphosphoric  acids  are  employed,  are  wholly  unneces- 
sary. 

Estimation  of  Albumen. — It  is  often  of  great  importance 
to  the  physician  to  know  the  quantity  of  albumen  which  is 
being  excreted  in  the  urine  from  day  to  day.  Unfortunately 
there  is  no  very  ready  method  of  performing  such  an  analy- 
sis. The  most  accurate  is  that  of  Berzelius.  The  urine  is 
carefully  filtered — 10-15  c.c.  of  the  filtrate  placed  in  a  por- 
celain dish,  carefully  acidulated  with  acetic  acid  and  evap- 
orated to  dryness  on  a  water-bath.  The  remainder  is 
extracted  first  with  hot  water,  and  then  with  alcohol,  placed 
upon  a  weighed  filter,  dried  at  ioo°C.,  and  finally  weighed. 
From  the  result  so  obtained  must  be  subtracted  the  quan- 
tity of  earthy  phosphates  and  coloring  matter  which  the 
residue  contains,  and  this  is  done  by  burning  the  filter  and 
the  coagulum  in  a  platinum  capsule,  and  deducting  the 
weight  of  the  ash  so  obtained. 

The  quantity  of  albumen  present  in  urine  may  likwise  be 
estimated  by  means  of  Laurent's  polarimeter.  The  urine 
must  be  rendered  very  clear  by  means  of  filtration,  or,  if 
this  fail,  by  the  addition  of  a  little  milk  of  lime  and  sub- 
sequent filtration.  If  the  tube  i  decimeter  long  be  used, 
then  each  degree  of  polarization  to  the  left  corresponds  to 


URINARY   SYSTEM.  209 

I  gramme  of  albumen  in  100  c.c.  of  urine.  This  method  of 
estimating  albumen  is,  however,  unfortunately  not  very  ac- 
curate. 

Senim-globulin  (Paraglobulin)  may  be  readily  detected  in 
urine  by  means  of  Hammarsten's  method. ^^  If  the  urine 
be  saturated  with  magnesium  sulphate,  which  is  to  be 
added  in  the  form  of  a  fine  powder,  the  globulin  will  sepa- 
rate out  as  a  white  flocculent  precipitate.  According  to 
Estelle,f  the  best  method  for  estimating  separately  the 
serum-albumen  and  the  serum-globulin  is  as  follows:  He 
takes  a  small  quantity  of  urine  and  adds  to  it  sulphate  of 
magnesia  until  no  more  will  dissolve.  The  mixture,  after 
having  been  shaken  for  ten  minutes,  is  poured  upon  a 
weighed  filter,  the  precipitate  washed  with  hot  water,  and 
finally  with  distilled  water,  until  the  sulphate  of  magnesiun 
is  completel}^  removed,  as  indicated  by  the  fact  that  chloride 
of  barium  when  added  to  the  washings  gives  no  longer  a 
precipitate.  The  filter  containing  the  precipitate  is  then 
dried  and  weighed.  In  this  way  the  quantity  of  serum-glo- 
bulin is  obtained.  The  serum-albumen  which  was  contained 
in  the  original  quantity  of  urine  is  now  contained  in  the 
first  filtrate,  and  its  amount  can  be  estimated  by  coagulating 
with  acetic  acid,  and  boiling,  filtering,  and  weighing  in  the 
manner  already  described.  The  clinical  bearings  of  serum- 
globulin  will  be  presently  referred  to. 

Propepto?i. — The  peculiar  albuminous  substance,  which 
Bence  Jones  first  described  J  as  occurring  in  the  urine 
of  a  patient  suffering  from  mollities  ossium,  is  in  all 
probability  identical  with  Schmidt-Miihlheim's  propepton 
and  with  Kiihne's  hemi-albumose.  It  is  an  intermediate 
product  of  the  digestion  of  pepsin  or  trypsin  before  pepton 
is  formed.  Virchow  found  §  it  to  be  present  in  the  medul- 
lary substance  of  the  bones  in  cases  of  mollities  ossium, 
Lassar  detected  it  ||  in  the  urine  of  petroleum  poisoning, 
and  Neale^  in  a  case  of  hsemoglobinuria.  Its  chief  peculi- 
arity is  that  though  precipitated  by  nitric  acid  in  the  cold 
it  becomes  dissolved  on  heating,  and  again  separates  out 
when  the  mixture  is  allowed  to  cooL 

*  Pfliiger's  Archiv.,  vols.  xvii.  and  xxii. 

f  Revue  Mensuelle,  1880.  p.  704. 

X  Phil  Tran^.,  1848. 

§  Virchow's  Archiv.,  iv. 

II   Ibid.,  Ixxvii. 

\  Lancet,  1879. 


2IO  MEDICAL  DIAGNOSIS. 

Detection. — The  urine  must  first  of  all  be  freed  from  se- 
rum-albumen and  serum-globulin.  If  the  urine  be  acidu- 
lated with  acetic  acid,  saturated  with  sulphate  of  magnesia, 
heated  to  boiling  and  then  filtered  hot,  these  two  substan- 
ces will  remain  on  the  filter  while  the  propepton  will  pass 
through  in  solution  in  the  hot  filtrate,  and  will  separate  out 
as  cooling  takes  place. 

Fibrin^  when  present  in  the  urine,  is  usually  in  the  form 
of  flakes,  and  is  due  to  inflammatory  action  in  the  kidneys 
and  urinary  passages.  It  is  probable  that  the  casts  of  the 
renal  tubules,  of  which  we  shall  presently  come  to  speak, 
are  chiefly  composed  of  fibrin.  The  spontaneous  coagula- 
tion of  chylous  urine  is  due  to  the  presence  of  fibrin. 

The  transitory  occurrence  of  albumen  in  the  urine  has 
been  frequently  observed  in  persons  who  are  apparently  in 
good  health.  Such  cases  have  been  described  by  Ulzmann.* 
Furbringer,f  Bamberger,J;  Runeberg,§  and  others.  Apart 
from  such  intermittent  albuminuria,  the  chief  conditions 
which  give  rise  to  albuminuria  of  a  more  or  less  permanent 
character  may  be  grouped  as  follows: 

(i.)  In  most  febrile  conditions  albumen  may  appear  in 
the  urine,  but  usually  only  in  small  quantity.  When  the 
amount  is  considerable,  it  points  to  the  occurrence  of 
Bright's  disease  as  a  complication. 

(2.)  In  such  affections  of  the  heart  or  lungs  which  lead  to 
circulatory  changes  in  the  kidneys,  in  particular  to  venous 
engorgement,  albumen  appears  in  the  urine;  but  here,  also, 
the  quantity  is  not  very  great. 

(3.)  In  Bright's  disease.  In  all  the  different  forms  of  this 
affection,  albumen  appears  in  the  urine.  Its  amount  is 
greatest  in  the  inflammatory  form  (in  severe  cases  the  urine 
may  even  become  solid  on  heating),  and  whenever  we  find 
a  large  quantity  of  albumen,  the  presence  of  this  form  of 
Bright's  disease  must  be  suspected.  In  the  cirrhotic  and 
waxy  forms,  when  these  are  uncomplicated  with  inflamma- 
tion, the  albumen  is  usually  only  present  in  very  small 
amount;  indeed,  albuminuria  often  does  not  show  itself  un- 
til some  considerable  time  after  the  commencement  of  the 
morbid  process  in  both  of  these  disorders,  and  when  it  does 

*  Wiener  med.  Presse,  1 8  70. 

+  Deutsck.  Archiv.  fur  kl.  med.,  vol.  xxvii. 

\  Wiener  med.    Wochensckr.,  188 1. 

§  J)futseh.  Archiv.  fiir  kl,  Med.y  vol.  XJfvi. 


URINARY   SYSTEM.  211 

set  in  it  is  often  subject  to  distinct  remissions,  appearing 
one  day  and  disappearing  the  next.  It  is  of  great  impor- 
tance to  distinguish  the  albuminuria  of  Bright's  disease  from 
that  which  occurs  in  other  disorders,  and  particularly  from 
that  of  heart  disease;  and  while  a  consideration  of  the  whole 
circumstances  of  the  case  will  generally  lead  to  a  correct  di- 
agnosis, the  most  important  point  is  the  presence  of  renal 
tube-casts  and  epithelium,  which  are  usually  more  or  less 
abundant  in  Bright's  disease. 

(4.)  Various  nervous  disorders  are  accompanied  with  al- 
buminuria. It  occurs,  for  example,  after  an  epileptic  fit, 
and  Warburton  Begbie  was  the  first  to  point  out*  that  al- 
bumen was  frequently  to  be  found  in  the  urine  in  cases  of 
exophthalmic  goitre. 

Albuminuria  also  occurs  in  cases  of  lead  poisoning,  and 
sometimes  in  pregnancy. 

In  regard  to  the  occurrence  of  serum-globulin  little  of 
diagnostic  importance  is  known.  Senator  states  that  while 
it  is  almost  always  present  in  albuminous  urine,  it  is  most 
abundant  in  the  waxy  form  of  Bright's  disease.  In  the  ar- 
ticle to  which  I  have  already  referred,  Estelle  states  that  it 
is  invariably  to  be  found  in  albuminuria;  that  it  is  often 
present  in  greater  quantity  than  the  serum-albumen;  and 
that  sometimes  it  exists  alone. 

The  albumen  found  in  the  urine  may  in  certain  cases  be 
derived  from  blood,  pus,  or  spermatic  fluid  with  which  the 
urine  has  become  mixed. 

Pepton. — Closely  allied  to  these  albuminous  substances 
stands  pepton,  which  Gerhardt  was  the  first  to  describe  as 
occurring  in  urine.  The  various  peptons,  which  are  the 
products  of  the  digestive  action  of  pepsin  and  the  pancre- 
atic juice  upon  albumen,  are  not  precipitated  by  acetic  acid 
and  ferrocyanide  of  potassium  (as  all  other  albuminous 
substances  are,  but  are  thrown  down  by  tannic  acid,  phos- 
phor-wolframic  acid,  and  certain  other  reagents.  Peptons 
further  give  the  biuret  reaction  (purple- red)  with  sulphate 
of  copper  and  caustic  soda,  and  also  a  red  color  with  Mil- 
Ion's  reagent. 

To  detect  pepton  in  albuminous  urine  the  albumen  must 
be  completely  separated  by  means  of  acetic  acid,  boiling 
and  filtration,  and  then  by  the  addition  of  hydrated  oxide 

*  Edin.  Med.  Journal^  1874. 


212  MEDICAL  DIAGNOSIS. 

of  lead,  the  lead  being  subsequently  removed  by  means" of 
sulphuretted  hydrogen.  This  process  must  be  repeated  until 
no  trace  of  albumen  can  be  detected  by  the  ferrocyanide  test. 
The  pepton  in  the  filtrate  is  then  precipitated  by  means  of 
a  solution  of  tannin,  the  precipitate  collected  and  washed, 
the  tannin  removed  by  means  of  the  hydrate  of  baryta,  and 
the  baryta  by  means  of  dilute  sulphuric  acid.  Finally,  the 
clear  filtrate  vi^hich  is  thus  obtained  is  tested  with  Millon's 
reagent,  when  a  red  color  will  show  the  presence  of  pepton. 

The  subject  of  peptonuria  has  been  chiefly  investigated 
by  Maixner"^  and  Hofmeister.f  According  to  the  former 
observer,  pepton  appears  in  the  urine  very  frequently  in 
those  diseases  in  which  the  formation  and  collection  of  pus 
play  a  prominent  part,  such  as  purulent  effusions  into  the 
pleural  and  peritoneal  cavities,  abscesses  in  various  situa- 
tions, pyonephrosis,  bronchorrhoea,  and  phthisis  when  cav- 
ities have  formed.  Peptonuria  also  occurs,  according  to 
the  same  author,  in  the  stage  of  resolution  of  croupous  pneu- 
monia, in  phosphorus  poisoning  (confirmed  by  the  observa- 
tions of  Schultzen  and  Riess),  in  typhoid  fever,  and  in  car- 
cinoma of  the  stomach. 

The  appearance  of  pepton  in  the  urine  is  to  be  explained 
on  the  supposition  that  when  it  passes  into  the  blood  it 
does  not  undergo  the  usual  change,  and  so  reaching  the 
kidneys  as  pepton,  it  is  excreted  as  such.  Plosz  and  Gyer- 
gyai;^  have  shown  that  when  peptones  are  injected  into  the 
blood-stream,  provided  that  they  are  not  thrown  into  the 
portal  circulation,  they  appear  unchanged  in  the  urine. 

Mucus. — A  small  quantity  of  mucus  is  present  in  normal 
urine;  but  in  such  affections  as  catarrh  of  the  bladder  or 
urethra,  it  may  be  much  increased.  It  is  sometimes  of  im- 
portance to  be  able  to  distinguish  mucus  from  pus  in  the 
urine.  This  is  readily  done  by  filtration,  when,  if  pus  be 
present,  the  filtrate  will  give  the  reactions  of  albumen;  but 
if  it  contain  mucus  it  will  give  that  which  is  characteristic 
of  mucin — /.  ^.,  when  acidulated  with  acetic  acid  a  precipi- 
tate of  mucin  separates  out  in  the  cold. 

Sugar. — Even  in  normal  urine  a  small  quantity  of  grape 
sugar  is  present;  but  its   quantity  is   so   minute  as  not  to 

*  Prager  Vierteljahrschrift,  cxliii.  (1879),  p.  78. 
f  Zeitschrift  filr  phys.  C/iemie.,  iv.  (1880),  p.  253. 
X  Pfi tiger's  Archiv.,  vol.  x. 


URINARY   SYSTEM.  213 

give  evidence  of  its  presence  with  the  ordinary  tests  which 
are  about  to  be  described.  When,  therefore,  sugar  is  de- 
tected by  tlieir  means,  it  is  present  in  abnormal  amount, 
and  constitutes  the  pathological  condition  termed  glyco- 
suria. 

Qualitative   Tests  for  Sugar. 

The  qualitative  tests  for  urine  containing  sugar  depend 
upon  the  coloration  caused  by  boiling  with  caustic  potash, 
upon  the  power  grape  sugar  possesses  of  reducing  h3^drated 
oxide  of  copper,  and  upon  the  evolution  of  carbonic  acid 
when  fermentation  is  set  up  by  the  addition  of  yea.st.  In 
all  cases  albumen,  if  present,  should  be  got  rid  of  by  coag- 
ulation and  filtration  before  these  tests  are  applied. 

1.  The  Caustic  Potash  Test  (Moore's). — The  urine  is  mixed 
in  a  test-tube  with  an  equal  quantity  of  liquor  potassae,  and 
the  upper  part  of  the  mixed  fluid  heated  to  boiling  in  the 
flame  of  a  spirit-lamp.  If  sugar  is  present  the  heated  por- 
tion will  assume  a  dark  brown  color.  Almost  all  urines, 
it  must  be  remembered,  darken  slightly  when  thus  treated; 
but  the  change  is  very  marked  w^hen  sugar  is  present.  This 
test  is  not  very  delicate,  but  is  readily  performed,  and  is 
useful  as  a  preliminary. 

2.  Trommers  Test. — To  a  small  quantity  of  urine  in  a  test- 
tube,  \  of  its  volume  of  liquor  potassae  is  added,  and  then 
a  drop  or  two  of  a  solution  of  sulphate  of  copper.  The 
precipitate  which  falls  will  redissolve  (the  more  readily  if 
sugar  be  present),  and  more  of  the  copper  solution  must  be 
added  until  a  small  quantity  of  the  hydrated  oxide  remains 
as  a  precipitate.  On  boiling  this  mixture  a  yellow  color 
will  show  itself  if  sugar  be  present,  and  will  pass  into  a 
reddish-yellow  granular  precipitate  of  the  suboxide  of 
copper. 

3.  Test  with  Fehling's  Solution. — Of  all  the  tests  for  sugar 
this  is  by  far  the  most  delicate  and  satisfactory.  The 
method  of  preparing  Fehling's  solution  will  be  described 
further  on.  A  small  quantity  of  that  solution  is  placed  in  a 
test-tube  heated  to  boiling,  and  then  a  drop  or  two  of  urine 
added.  If  sugar  be  present,  reduction  of  the  copper  in 
Fehling's  solution  will  at  once  take  place,  giving  rise  to  a 
red  precipitate.  Fehling's  solution  is  liable  to  undergo  de- 
composition when  kept  for  some  time,  and  it  will  then  of 
itself  become  reduced  on  boiling.  If,  however,  it  be  always- 
boiled  previous  to  the  addition  of  the  urine,  no  error  can- 


214  MEDICAL  DIAGNOSIS. 

take  place,  for  if  the  solution  remain  clear  on  boiling,  it  is 
in  a  fit  state  for  use. 

4.  Fermentation  Test. — Under  the  influence  of  yeast,  grape 
sugar  breaks  up  into  alcohol  and  carbonic  acid,  and  this 
evolution  of  carbonic  acid  has  been  made  the  basis  of  an- 
other qualitative  test  for  the  presence  of  sugar.  It  is  most 
readily  performed  by  taking  two  test-tubes  or  narrow 
phials,  one  filled  with  water  and  the  other  with  urine,  add- 
ing to  each  a  small  quantity  of  yeast,  covering  them  with 
a  saucer,  and  inverting  them.  If  sugar  be  present  in  the 
urine,  carbonic  acid  gas  will  collect  at  the  upper  part  of  that 
test-tube.  A  few  bubbles  of  gas  may  come  from  the  yeast 
itself,  but  the  second  test-tube  containing  water  will  show 
these  also,  so  that  any  mistake  is  hardly  possible.  This  test 
is  not  very  sensitive.  According  to  Roberts,*  urines  con- 
taining two  grains  and  a  half  of  sugar  in  the  ounce,  and 
under,  yield  no  sign  of  sugar  with  this  test. 

Quantitative  Estimation  of  Sugar. — A  considerable  number 
of  methods  have  been  devised  for  this  purpose.  I  propose, 
however,  only  to  describe  two — viz.,  first,  the  modification  of 
the  process  of  Fehling  which  Dr.  Pavy  has  recommended,! 
and,  second,  the  method  by  means  of  the  polarimeter. 

Pavys  Method. — The  principle  upon  which  Fehling' s  meth- 
od for  the  volumetric  analysis  of  sugar  depends  is  the  re- 
ducing action  which  that  substance  has  upon  hydrated  ox- 
ide of  copper;  but  the  reaction  is  so  much  obscured  by  the 
red  precipitate  of  the  sub-oxide  which  is  thrown  down  that 
the  results  are  not  very  accurate.  Pavy  therefore  devised 
the  following  method,  in  which  ammonia  is  made  use  of  to 
prevent  the  precipitation  of  the  sub-oxide.  If  ammonia  be 
added  to  Fehling's  solution,  and  the  mixture  be  boiled,  a  suf- 
ciency  of  grape  sugar  may  be  added  to  the  mixture  to  re- 
duce all  the  copper  and  render  the  solution  colorless,  with- 
out any  precipitation  taking  place. 

The  preparation  of  the  copper  solution  is  carried  out  as 
follows:  An  ordinary  Fehling's  solution  is  made  by  dis- 
solving 34.639  grammes  of  pure  sulphate  of  copper  in  water 
and  diluting  to  500  c.  c.  The  solution  so  obtained  is  mixed 
with  another  solution,  prepared  by  dissolving  173  grammes 
of  tartrate  of  potassium  and  sodium  in  water,  mixing  it 
with  100  c.  c.  of  liquor  sodae  (sp.  gr.  1.34),  and  diluting  the 

*  "  Urinary  and  Renal  Diseases,"  4th  ed.,  p.  183. 
\  Proceedings  of  the  Royal  Society  of  London,  1879. 


URINARY   SYSTEM.  215 

mixture  to  500  c.  c.  When  these  two  solutions,  each  of 
500  c.  c,  are  united,  we  obtain  one  litre  of  ordinary  Feh- 
ling's  solution.  Of  this  solution  120  c.  c.  are  now  taken, 
mixed  with  300  c.  c.  of  strong  ammonia  (sp.  gr.  .880),  and 
diluted  up  to  a  litre  with  distilled  water.  This  constitutes 
Pavy's  standard  solution,  and  of  it  20  c.  c.  correspond  to 
o.oi  gramme  of  grape  sugar. 

The  analysis  is  carried  out  as  follows:  A  flask  of  about 
80  c.  c.  capacity  is  taken  and  fitted  with  a  cork,  through 
which  two  holes  are  bored,  one  of  which  receives  the  deliv- 
ery tube  of  a  Mohr's  burette,  and  into  the  other  is  adapted 
a  bent  glass  tube  to  allow  of  the  escape  of  air  and  steam. 
The  burette,  filled  with  the  urine,*  is  fixed  in  its  stand,  and 
the  flask,  into  which  20  c.  c.  of  the  copper  solution  have 
been  measured,  allowed  to  hang  free,  so  that  nothing  may 
obstruct  the  full  view  of  its  contents.  Heat  is  now  to  be 
applied  to  the  flask,  and  after  the  solution  has  boiled  for  a 
few  minutes,  so  that  all  air  has  been  expelled  from  the  flask, 
the  urine  is  allowed  to  flow  into  it  until  the  copper  solution 
has  become  completely  colorless.  This  marks  the  end  of 
the  reaction.  The  quantity  of  urine  used  contains  o.oi 
gramme  of  grape  sugar. 

Method  by  Circular  Polarization, — Grape  sugar  when  in  so- 
lution possesses  this  peculiar  property,  that  if  a  beam  of 
polarized  light  pass  through  it  the  beam  becomes  rotated 
to  the  right,  and  the  degree  of  this  rotation  is  in  exact  pro- 
portion to  the  amount  of  sugar  contained  in  solution,  and 
the  length  of  the  column  of  solution  which  the  light  traver- 
ses. Several  instruments  have  been  devised  for  the  purpose 
of  measuring  the  degree  of  this  right-handed  rotation,  and 
so  estimating  the  quantity  of  grape  sugar  present.  Of  these, 
the  best  known  is  the  saccharimeter  of  Soleil-Ventzke.  Its 
construction  is  complicated,  and  I  do  not  propose  to  de- 
scribe it  in  detail.  It  consists  of  two  short  brass  tubes  lying 
in  line,  and  containing  various  polarizingprisms.  Between 
these  two  end  tubes  fits  in  the  tube  containing  the  urine  to 
be  tested.  By  means  of  a  milled  head  two  quartz  prisms 
are  moved  so  as  to  compensate  for  the  rotation  effected  by 
the  sugar  solution,  and  the  amount  of  this  movement  is  reg- 
istered by  means  of  an  attached  scale  and  vernier.  When 
this  scale  stands  at  zero,  and  when  no  sugar  solution  is  in 

*  It  is  best  in  the  first  instance  to  dilute  the  urine  in  the  proportion  of 
10  to  100. 


2l6  MEDICAL  DIAGNOSIS. 

the  tube,  the  appearance  presented  on  looking  through  the 
instrument  is  a  circular  field  divided  into  two  lateral  halves, 
each  of  which  presents  the  same  tint.  If  now  the  tube  con- 
taining diabetic  urine  be  slipped  into  its  place,  the  light  be- 
comes rotated,  and,  on  account  of  the  special  arrangements 
of  the  instrument,  the  field  of  vision  assumes  a  different 
color  on  the  two  sides.  By  slowly  moving  the  screw  which 
commands  the  quartz  prisms,  these  two  colors  become  gra- 
dually altered  in  tint  until  they  again  exactly  correspond 
to  each  other.  The  amount  of  movement  required  to  effect 
this  is  now  to  be  read  off  on  the  scale  by  means  of  the  ver- 
nier, and  by  a  simple  calculation  we  can  learn  the  percent- 
age of  sugar  in  the  urine  in  question.  With  a  tube  one 
decimetre  long  each  degree  of  the  scale  represents  i  gramme 
of  grape-sugar  in  loo  c.  c.  of  urine. 

The  urine  must  always  be  rendered  perfectly  clear  by 
means  of  filtration  before  it  is  placed  in  the  tube  of  the 
saccharimeter,  and  if  it  is  highly  colored  it  is  well  to  re- 
move the  pigment  by  precipitation  with  acetate  of  lead 
and  filtration.  Albumen  rotates  polarized  light  to  the  left, 
as  has  been  already  mentioned,  hence  it  is  absolutely  nec- 
essary to  get  rid  of  this  substance,  if  it  be  present,  before 
the  saccharimeter  is  used. 

Laurent's  polarimeter  is  more  accurate  in  its  readings, 
and  is  to  be  preferred.  The  calculation  is  the  same  as  that 
of  the  Soleil-Ventzke  saccharimeter. 

Saccharine  urine  is  rarely  met  with  except  in  cases  of 
diabetes  mellitus.  Diabetic  urine  possesses,  when  the  dis- 
ease is  fully  developed,  various  well-marked  characteristics. 
It  is  large  in  quantity,  sometimes  reaching  so  high  a  figure 
as  15  or  16  pints,  and  correspondingly  pale,  but  neverthe- 
less possesses  a  high  specific  gravity,  ranging  from  1040  to 
1050,  or  even  higher.  The  quantity  of  the  nitrogenous 
substances  excreted  is  usually,  if  not  invariably,  very  much 
increased.  The  quantity  of  grape  sugar  excreted  may,  in 
severe  cases,  be  as  high  as  25  or  30  ounces  in  twenty-four 
hours. 

In  certain  cases  of  diabetes  there  maybe  felt  in  the  urine, 
towards  the  termination  of  the  case,  a  peculiar  etherial 
odor,  the  result  of  the  formation  of  aceton;  and  to  the  pres- 
ence of  this  substance  in  the  blood  have  been,  by  some,  as- 
cribed the  symptoms  of  diabetic  coma.  Such  urine  usually 
assumes  a  reddish-brown  color  on  the  addition  of  chloride 
of  iron,  and  this  reaction  is  supposed  to  be  due  to  the  pres- 


URINARY   SYSTEM.  2lJ^ 

ence  of  ethyldiacetic  acid,  which,  as  Geuther  and  Gerhardt 
have  pointed  out,  readily  breaks  up  into  aceton,  alcohol, 
and  carbonic  acid.  Much  uncertainty,  however,  involves 
this  interesting  point. 

Blood  may  be  found  in  the  urine  as  such  (haematuria),  or 
only  blood  pigment  may  be  present  (haemoglobinuria);  and 
these  two  conditions  are  readily  distinguished  by  the  fact 
that  in  the  former  case  blood  corpuscles  are  found  on  mi- 
croscopic examination,  while  in  the  latter  they  are  absent. 
The  admixture  of  even  a  very  small  quantity  of  blood  gives 
the  urine  a  peculiar  smoky  appearance.  When  it  is  present 
in  larger  quantity  the  urine  becomes  bright-red  or  dark- 
brown.  Small  quantities  of  blood  are  best  detected  by 
means  of  the  microscope,  but  when  no  corpuscles  or  crys- 
tals of  haematin  are  present,  recourse  may  be  had  to  the 
spectroscope.  If  oxyhaemoglobin  be  present,  two  dark  ab- 
sorption bands  will  be  seen  lying  between  the  lines  D  and 
E.  On  the  addition  of  sulphide  of  ammonium  to  the  spe- 
cimen of  the  urine  the  spectrum  of  reduced  haemoglobin 
will  appear — a  broad  dark  band  also  lying  between  D  and 
E,  and  less  well  defined  than  the  bands  of  oxyhaemoglobin. 

In  cases  of  haematuria  it  is  important  to  ascertain  from 
what  point  in  the  urinary  tract  the  blood  comes,  and  this 
is  not  usually  difficult.     The  hemorrhage  may  come: 

(i.)  Fro77i  the  Urethra. — The  blood  is  mixed  with  the  first 
portion  of  urine  passed,  often  being  expelled  as  a  long  clot, 
and  it  continues  to  flow  in  the  intervals  of  micturition. 

(2.)  From  the  Neck  of  the  Bladder,  or  prostatic  part  of  the 
urethra.  In  this  case  the  blood  usually  appears  only  at  the 
very  end  of  micturition,  when  the  sphincter  vesicae  begins 
to  contract. 

(3.)  From  the  Bladder. — The  blood  is  usually  coagulated, 
and  is  passed  in  clots  as  large  as  the  calibre  of  the  urethra 
will  allow  to  escape. 

(4.)  From  the  Ureters. — In  this  case  the  blood  often  ap- 
pears in  the  form  of  long  worm-like  clots,  which  are  casts 
of  the  ureters. 

(5.)  From  the  Kidneys. — When  the  blood  comes  from  the 
kidneys  it  is  uniformly  diffused  through  the  urine,  is  almost 
never  in  very  large  quantity,  and  when  the  urinary  sedi- 
ment is  examined  there  are  found  tube  casts,  usually  con- 
taining blood  corpuscles. 

HcBmoglobimi7'ia   appears    in    such    diseases    as    purpura, 


2l8  MEDICAL  DIAGNOSIS. 

scurvy,  pyaemia,  severe  typhus,  small-pox,  etc.,  and  result 
from  a  breaking  down  of  the  red  blood  corpuscles  in  the 
blood  stream,  and  the  consequent  liberation  of  the  haemo- 
globin they  contain,  which  then  escapes  into  the  urine.  It 
also  occurs  in  a  paroxysmal  form,  each  paroxysm  being  ac- 
companied with  ague-like  symptoms,  and  is  then  usually 
the  result  of  a  chill,  although  sometimes  it  may  be  traced 
to  malarial  infection. 

Bile  Pigment  appears  in  the  urine  in  cases  of  jaundice. 
Its  presence  is  readily  detected  by  the  play  of  colors  which 
ensues  when  the  urine  which  contains  the  pigment  comes 
in  contact  with  nitric  acid.  If  a  little  urine  containing  bile 
pigment  is  placed  in  a  conical  glass,  and  a  few  drops  of 
nitric  acid  (which  has  been  allowed  to  stand  exposed  to 
light  for  some  time,  and  is  therefore  mixed  with  nitrous 
acid)  are  allowed  to  run  down  the  edge  of  the  glass  and 
collect  at  the  bottom  of  the  vessel,  a  series  of  colored  rings 
will  form  in  the  following  order — yellow,  violet,  blue  and 
green.  A  still  better  method  is  to  filter  the  urine  and  then 
to  allow  a  drop  of  nitric  acid  to  fall  on  the  surface  of  the 
filter.  The  play  of  colors  ending  in  green  will  then  be  very 
distinctly  seen. 

Urine  containing  bile  pigment  is  usually  yellowish  or 
greenish.  It  froths  easily,  and  the  bubbles  of  foam  have  a 
greenish-yellow  color. 

Bile  Acids  are  found  in  the  urine  in  considerable  quantity 
in  hepatogenic  icterus.  When  to  a  solution  of  these  acids 
a  little  cane  sugar  is  added,  and  then  a  drop  or  two  of  sul- 
phuric acid,  a  beautiful  purple  color  develops  itself.  On 
this  reaction  depends  their  detection  in  urine.  In  a  small 
quantity  of  urine  a  little  sugar  is  dissolved,  a  strip  of  filter 
paper  is  dipped  in,  and  then  allowed  to  dry.  If  now  a  drop 
of  sulphuric  acid  be  allowed  to  fall  upon  the  paper  a  purple 
ring  will  appear  round  it. 


URINARY   SYSTEM.  219 

CHAPTER  XXV. 
Urinary  System — {continued), 

URINARY   SEDIMENTS. 

In  order  to  examine  the  sediment  of  a  urine  it  is  best  to 
allow  the  urine  to  stand  covered  for  some  hours  in  a  coni- 
cal glass,  after  which  a  drop  or  two  of  the  sediment  which 
has  collected  may  be  removed  by  means  of  a  pipette  and 
examined  microscopically.  It  is  of  considerable  importance 
to  ascertain  the  reaction  of  the  urine  at  the  time  it  is  de- 
positing, and  to  note  whether  the  specimen  has  been  freshly 
passed  or  not. 

Urinary  deposits  are  divided  into  two  classes — organic 
and  inorganic.  Of  these  the  first  is  by  far  the  most  im- 
portant. 

Organic  Deposits, 

These  include  blood  and  pus  corpuscles,  epithelium,  tube- 
casts,  spermatozoa,  and  micro-ors:anisms. 

1.  Blood  Corpuscles  are  found  in  the  urine  in  cases  of 
haematuria.  When  the  urine  is  acid  the  corpuscles  pre- 
serve for  some  time  their  normal  appearance  ;  but  when 
it  is  alkaline,  or  very  dilute,  the  red  corpuscles  swell  up, 
lose  their  biconcave  shape,  and  become  pale.  On  the 
other  hand,  when  the  urine  is  concentrated  they  shrink 
up  and  become  crenated.  It  is  very  rare  to  find  rouleaux 
of  corpuscles.  They  are  only  seen  in  cases  of  profuse 
bleeding  from  the  bladder.  Occasionally  crystals  of  hsem- 
atoidin  may  be  found. 

2.  Pus  Corpuscles  when  present  in  any  quantity  form  a 
yellowish-white  deposit,  which  is  usually  easily  recognizable 
by  the  naked  eye.  Microscopically,  the  corpuscles  present 
as  a  rule  their  normal  appearance;  but  if  the  urine  be' 
strongly  alkaline,  they  tend  to  run  together  and  form  a  ho- 
mogeneous mass.  If  there  be  doubt  as  to  whether  a  de- 
posit consists  of  pus,  it  is  only  necessary  to  add  a  small 
piece  of  caustic  potash,  and  to  stir  with  a  glass  rod,  when,- 


220  MEDICAL  DIAGNOSIS. 

if  the  sediment  be  formed  of  pus,  it  will  become  tenacious, 
glassy,  and  semi-solid. 

The  presence  of  pus  in  the  urine  is  always  a  sure  sign 
that  there  exists  an  acute  or  chronic  inflammation  at  some 
part  of  the  urinary  tract — renal  abscess,  pyelitis,  cystitis,  or 
urethritis.  In  women,  it  must  be  remembered,  pus  flowing 
from  the  genital  tract  may  become  mixed  with  the  urine. 

3.  Epithelium. — The  epithelial  cells  in  the  urine  are  best 
seen  when  stained  with  eosin  or  fuchsin.  They  may  be 
derived  from  any  portion  of  the  urinary  tract.  The  epithe- 
lium of  the  urinary  tubules  consists  of  round  or  polygonal 
cells,  each  having  a  large  and  sharply  defined  nucleus. 
Those  of  the  pelvis  of  the  kidney  are  conical,  with  one,  or 
sometimes  two,  tail-like  processes.  The  large  irregular 
pavement  epithelial  cells  which  are  often  seen  in  the  urine 
come  from  the  bladder  or  vagina. 

4.  Renal  Tube-casts. — Before  examining  the  urine  for 
tube-casts,  a  specimen  should  be  allowed  to  stand  in  a  con- 
ical glass  for  twenty-four  hours,  at  the  end  of  which  time  a 
few  drops  of  the  sediment  maybe  raised  by  means  of  a 
pipette  and  examined  microscopically  {inde  fig.  10).  Stain- 
ing with  eosin  or  metliyl-green  will  make  the  tube-casts 
more  distinct. 

Renal  tube-casts*  are  almost  invariably  associated  with 
albuminuria,  and  most  frequently  with  Bright's  disease,  but 
they  occasionally  occur  when  no  albumen  can  be  detected 
in  the  urine.  They  are,  as  a  rule,  formed  of  fibrin,  and  are, 
as  their  name  implies,  casts  of  the  renal  tubules,  in  the  ma- 
jority of  cases  of  the  convoluted  tubules  of  the  cortex.  The 
chief  forms  of  tube-casts  are  the  following: 

(i.)  Epithelial  Casts. — In  these  the  fibrinous  cylinder  has 
become  covered  over  with  epithelial  cells  which  have  been 
detached  from  the  lining  membrane  of  the  tubule.  These 
cells  may  be  more  or  less  cloudy  and  swollen.  Such  tube- 
casts  are  found  in  the  inflammatory  form  of  Bright's  disease. 

(2.)  Pus  Casts. — Casts  containing  pus  corpuscles  im- 
bedded in  them  are  sometimes  met  with.  According  to  Dr. 
George  Johnson,  they  are  diagnostic  of  glomerulo-nephritis. 

(3.)  Fatty  Casts. — Very  frequently  casts  are  found  studded 

*See  an  article  by  Dr.  George  Johnson,  on  the  various  forms  of  renal 
tube-casts. — British  Medical  Jotirnal,  March,  1882. 


URINARY   SYSTEM.  221 

over  with  oil  globules.  These  globules  are  the  result  of 
fatty  degeneration  of  the  renal  epithelium,  and  such  casts 
are  met  with  in  the  second  stage  of  inflammatory  Bright's 
disease. 

(4.)  Gramdar  Casts. — Dark  opaque  granular  casts  are  also 
the  result  of  epithelial  degeneration  in  the  renal  tubules. 

(5.)  Blood  Casts  may  either  consist  wholly  of  blood,  the 
corpuscles  being  closely  applied  to  one  another,  or  fibrinous 
casts  may  be  seen  containing  one  or  two  blood  corpuscles 
imbedded  in  them.  Such  casts  point  to  capillary  rupture, 
and  are  found  in  acute  inflammatory  Bright's  disease. 

(6.)  Hyalijie  Casts  are  clear,  homogeneous,  and  transpar- 
ent, sometimes  so  delicate  in  structure  as  to  be  barely  visi- 
ble. They  are  for  the  most  part  formed  in  the  convoluted 
tubules  of  the  cortex,  and  have  therefore  a  correspondingly 
convoluted  form.  The  smaller  specimens  have  been  moulded 
within  the  lumen  of  a  tubule  which  still  retains  its  epithe- 
lium, while  the  larger  varieties  have  been  formed  in  tubules 
previously  denuded  of  epithelium,  and  therefore  of  greater 
capacity.     Hyaline  casts  point  to  chronic  Bright's  disease. 

Occasionally  hyaline  casts  may  be  found  which  exhibit 
the  amyloid  reaction,  becoming  reddish-brown  on  the  addi- 
tion of  iodine,  and  dirty  violet  on  the  further  addition  of 
sulphuric  acid;  and  giving  also  a  beautiful  violet  with 
methyl-green,  which  tinges  other  casts  green.  Such  waxy 
or  amyloid  casts  are  more  strongly  refractive  than  the  ordi- 
nary hyaline  variety,  and  being  less  flexible  they  exhibit 
deep  fissures  where  they  have  been  torn  asunder  in  passing 
through  the  straight  tubules. 

The  student  should  be  careful  not  to  mistake  for  tube 
casts  these  mucus  coagula  which  are  so  often  found,  inclos- 
ing in  their  meshes  whatever  amorphous  inorganic  deposit 
the  urine  may  happen  to  contain. 

5.  Spermatozoa  are  occasionally  found  in  urine.  They 
preserve  their  normal  appearance  for  a  long  time.  If  the 
urine  be  very  fresh,  they  may  even  be  seen  in  active  mo- 
tion, but  these  movements  are  soon  lost.  Urine  which  con- 
tains spermatozoa  becomes  alkaline  very  rapidly. 

6.  Micro-Organisms. — Very  many  forms  of  lower  organ- 
isms are  found  in  urine.  Many  of  these  only  develop  after 
the  urine  has  been  voided,  and  are  derived  from  the  atmo- 
sphere.    Occasionally,  however,  urine  as  it  leaves  the  body 


222 


MEDICAL  DIAGNOSIS. 


will  be  found  to  contain  such  organisms.  These  may  be 
the  result  of  the  introduction  of  a  catheter  which  has  not 
been  properly  purified,  but  in  other  cases  they  are  undoubt- 
edly derived  from  the  blood.  The  latter  are  most  frequent 
in  acute  infectious  disorders.*  Roberts  has  described  fa 
peculiar  condition  which  he  calls  bacilluria,  in  which  the 
urine  when  passed  is  opalescent  from  the  presence  of  enor- 
mous numbers  of  bacilli.  The  reaction  is  acid,  and  when 
the  urine  has  stood  for  some  time  the  organisms  sink  to 
the  bottom  of  the  glass,  leaving  the  supernatant  fluid  clear. 
Very  rarely  the  embryo  forms  of  parasites  which  infest 
the  blood  are  found  in  the  urine. 


Inorganic  Sediments. 

The  reaction  of  the  urine  in  which  the  sediment  is  found 
gives  an  important  indication  as  to  its  constitution,  certain 
substances  separating  out  only  in  acid  urine,  while  others 
are  only  found  when  the  reaction  is  alkaline.  The  follow- 
ing table  shows  what  the  physician  may  be  prepared  to 
meet  with  in  each  case: — 


Acid  Urine. 

Amorphous — 

Urates  of  potash  and  soda. 


Crystalline — 

ia.')  Uric  acid. 

{b.)  Oxalate  of  lime. 

(^.)    Leucin. 

id.)  Ty rosin. 

(^.)    Cholesterin. 

(/.)  Cystin. 


Alkaline  Urine, 

Amorphous — 
(a.)  Neutral  phosphate  of  lime. 
(<5.)  Carbonate  of  lime. 

Crystalline — 

(<2.)  Urate  of  ammonium. 

(3.)  Crystallized  phosphate  of 
lime. 

(r.)  Phosphate  of  magnesium. 

(</.)  Phosphate  of  ammonium  and 
magnesium  (triple  -  phos- 
phate). 


Sediments  of  Acid  Urine. 

I.  Urates. — The  amorphous  deposit  of  urates,  which  is  so 
frequently  met  with  even  in  healthy  urine,  consists  in  the 
main  of  urate  of  soda,  but  may  also  contain  urate  of  potash 
and  of  magnesia.  To  the  naked  eye  the  deposit  of  amor- 
phous urates  has  a  reddish,  brick-dust  color,  due  to  pigmen- 
tation with  uroerythrin.     When  the  urine  has  been  allowed 


*  Kannenberg,  Zeitschr.^  f.  kl.  tned.,  i.  p.  506. 

f  Trans,  of  the  International  Medical  Congress^  1881. 


URINARY   SYSTEM. 


223 


to  stand  in  a  glass  for  some  time,  and  deposit  these  urates, 
a  peculiar  bloom  may  be  seen  upon  the  sides  of  the  glass 
when  it  is  inclined,  which  is  a  characteristic  and  unmistaka- 
ble sign  of  the  presence  of  urates.  Microscopically  this  de- 
posit appears  amorphous  and  finely  granular.  On  warm- 
ing the  microscopic  slide  the  sediment  becomes  dissolved, 
and  it  separates  out  again  on  cooling,  and  the  same  reac- 
tion can  be  very  readily  seen  with  a  larger  quantity  in  a 
test-tube. 

In  health  a  deposit  of  urates  often  occurs  after  profuse 
sweating  and  violent  exercise,  in  cold  weather.  Pathologi- 
cally this  deposit  is  found  in  all  febrile  conditions,  in  grave 
organic  disease,  particularly  of  the  liver,  and  in  dyspepsia. 

2.  Uric  Acid. — The  more  important  points  connected  with 
the  elimination  of  uric  acid  have  been  stated.     There  only 
now  remain  for   consideration    the    appearances    which    a 
deposit  of  this  substance  pre- 
sents in  the  urine. 

The  crystals  of  uric  acid 
can  usually  be  seen  as  bright 
reddish-brown  grains  adher- 
ing to  the  sides  of  the  glass, 
or  forming  a  layer  at  the  bot- 
tom. They  closely  resemble 
the  grains  of  cayenne  pepper. 
Microscopically  these  crystals 
vary  much  in  shape.  They 
may  take  the  form  of  four- 
sided  tables,  of  six-sided 
rhombs,    or     they     may    be 

lozenge-shaped,  ovoid,  or  bar-  pi^.xo.  Uric  Acid  Crystals  and  Tube-casts. 

rel-shaped,  or  still  more  elon- 
gated and  arranged  in  a  stellate  fashion.  In  whatever 
form  uric  acid  appears  the  crystals  are  always  more  or 
less  yellow;  and  as  no  other  crystal  which  spontaneously 
separates  out  from  urine  is  so  tinted,  there  can  be  no  diffi- 
culty in  its  recognition. 

3.  Oxalate  of  Livie  appears  in  the  urine  as  small  octahedra, 
which  may  be  more  or  less  elongated,  or  in  the  form  of 
dumb-bells  or  small  ovoids.  To  the  naked  eye  the  deposit 
appears  as  a  white,  undulating,  clearly-defined  layer,  rest- 
ing upon  a  grayer  deposit  beneath. 

Oxalic  acid  occurs  normally  in  urine  in  minute  quanti- 
ties, and  is  much  increased  by  the  consumption  of  sugar, 


224  MEDICAL   DIAGNOSIS. 

and  of  such  vegetables  as  contain  it  in  their  tissues.  It 
constitutes  one  of  the  last  stages  in  the  decomposition  of 
the  effete  tissues,  and  probably  results  from  impeded  meta- 
morphosis (Beneke).  Oxaluria  is  frequently  produced  by 
conditions  which  interfere  with  respiration  and  circulation. 

As  regards  the  symptoms  of 
oxaluria,  there  is  much  differ- 
ence of  opinion,  but  it  appears 
certain  that  in  many  cases  at 
all  events  the  appearance  of 
oxalate  of  lime  in  quantity  in 
the  urine  is  accompanied  with 
a  well-marked  train  of  symp- 
toms. The  patient  is  usu- 
ally emaciated,  very  nervous, 
extremely  hypochondriacal, 
and  irritable.  There  is  pain 
across  the  small  of  the  back,  a 
Fig.  II.  Oxalate  of  Lime  and  Cystin.  degree  of  irritability  of  the 
bladder,  and  general  muscular  weakness.  It  must  be  re- 
membered, however,  that,  on  the  one  hand,  such  a  train  of 
symptoms  may  be  present  in  full  development  without  any 
oxaluria,  and,  on  the  other,  that  crystals  of  oxalate  of  lime 
may  be  very  abundant  without  producing  any  such  symp- 
toms. 

4.  Leucin  and  Tyrosin. — Leucin  appears  in  the  urine  mi- 
croscopically in  the  form  of  larger  or  smaller  yellowish- 
brown  balls,  which  sometimes  show  distinct  striation.  Ty- 
rosin, on  the  other  hand,  appears  under  the  microscope  as 
sheaves  of  silky  glittering  needle-shaped  crystals.  These 
two  substances  result  from  the  decomposition  of  albumen 
and  other  nitrogenous  bodies,  and  when  they  appearin  the 
urine  they  are  a  proof  of  incomplete  oxidation  of  these 
substances,  and  they  therefore  precede  urea.  Leucin  and 
Tyrosin  are  very  rarely  met  with  in  urinary  deposits.  Their 
occurrence  is  almost  confined  to  cases  of  acute  yellow  atro- 
phy of  the  liver,  and  they  are  not  by  any  means  invariably 
met  with  in  that  disease. 

5.  Cholesterin  and  other  fats  are  found  in  the  urine  in  cases, 
of  chyluria.  The  deposit  consists  of  minute  oil  globules, 
and  when  dissolved  in  a  mixture  of  alcohol  and  ether,  and 
the  solution  allowed  to  evaporate,  clear  plates  of  choles- 
terin often  crystallize  out. 

6.  Cystm  appears   in   the   urine  in  the  form  of  six-sided 


URINARY   SYSTEM. 


225 


plates,  which  are  insoluble  in  water  and  in  acetic  acid,  but 
which  readily  dissolve  in  hydrochloric  acid  and  ammonia. 
The  pathology  of  cystinuria  is  very  obscure. 


Sediments  of  Alkaline  Urine. 

The  inorganic  sediments  which  are  found  in  alkaline 
urine  may  consist  of  various  salts  of  phosphoric  acid,  of 
carbonate  of  lime,  or  of  urate  of  ammonium. 

1.  Amorphous  phosphate  of  lime  forms  a  whitish  flocculent 
deposit,  which  is  not  dissolved  by  heat,  but  at  once  passes 
into  solution  on  the  addition  of  a  drop  or  two  of  acetic  or 
nitric  acid.  Under  the  microscope  this  deposit  is  seen  to 
consist  of  fine  granules,  arranged  usually  in  irregular  groups. 
In  microscopic  appearance  they  closely  resemble  amor- 
phous urates,  but  the  reaction  of  the  urine  will  at  once  in- 
dicate their  nature. 

2.  Cj'ystallized  Phosphate  of  Lwie  {^Stellar  Phosphate). — The 
crystals  of  this  salt  are  found 

in  the  urine  in  the  form  of 
rods,  which  either  lie  separate- 
ly or  are  united  to  one  another 
so  as  to  form  rosettes  or  sheaf- 
like bundles.  This  is  a  some- 
what rare  deposit,  and  is  said 
to  possess  a  graver  significance 
than  is  attachable  to  the  other 
varieties  of  phosphates. 

3.  Phosphate  of  A7timonium, 
and  Magjiesiicm  \Triple  Phos- 
phate^.— This  salt  forms  com- 
paratively large  clear  crystals, 
which  may  frequently  be  rec- 
ognized by  the  naked  eye  as 
bright  sparkling  points  adher- 
ing to  the  sides  of  the  glass.  Examined  microscopically,  they 
are  found  to  be  of  varying  form,  usually,  however,  having 
the  shape  of  a  triangular  prism  with  bevelled  ends,  and 
presenting  from  above  the  appearance  of  a  glass  knife-rest. 
Most  usually  the  deposition  of  these  crystals  is  simply  due 
to  the  ammoniacal  decomposition  of  the  urine. 

4.  Phosphate  of  Mag7iesium  is  occasionally,  though  rarely, 
encountered  in  the  urine  in  form  of  crystals — flat  tables 
elongated  in  shape,  clear  and  glassy. 


Fig, 


12. — Triple  Phosphate  and  Stellar 
Phosphate. 


226  MEDICAL   DIAGNOSIS. 

5.  Carbonate  of  Lime. — In  human  urine  carbonate  of  lime 
only  occurs  in  an  amorphous  form.  It  dissolves  in  acetic 
acid  with  effervescence.  In  the  urine  of  the  horse  it  forms 
spheres  marked  v^^ith  radiating  lines. 

6.  Urate  of  Ammonia  is  found  virhenever  the  urine  be- 
comes strongly  ammoniacal,  in  the  form  of  opaque  brown- 
ish spheres,  which  may  be  either  smooth  on  the  surface,  or 
may  be  covered  with  minute  spikes.  Sometimes  this  salt 
crystallizes  in  the  form  of  minute  clear  dumb-bells.  It  has 
no  particular  clinical  significance. 


CHAPTER  XXVI. 

Reproductive  System. 

The  diseases  of  the  male  generative  organs  fall,  almost 
without  exception,  within  the  domain  of  surgery.  The  only 
disorders  with  which  the  physician  is  called  upon  to  deal 
are  impotence  and  spermatorrhoea,  and  as  their  diagnosis 
does  not,  as  a  rule,  present  any  feature  of  difficulty,  I  do 
not  propose  to  consider  them  here. 

Those  diseases  which  are  met  with  in  connection  with 
the  female  organs  of  reproduction  usually  receive  the  spe- 
cial study  of  the  gynecologist,  and  are  fully  treated  of  in 
works  devoted  to  that  branch  of  medicine.  Inasmuch,  how- 
ever, as  very  many  of  the  disorders  of  the  system  generally 
which  are  encountered  in  women  take  origin  in  some  dis- 
turbance of  the  generative  functions,  or  are  aggravated 
thereby,  it  is  very  important  for  the  physician  to  possess 
some  knowledge  regarding  their  diagnosis.  I  shall,  there- 
fore, in  very  brief  language,  indicate  the  chief  lines  of  in- 
quiry in  connection  with 

THE   FEMALE    REPRODUCTIVE    ORGANS   AND    FUNCTIONS.* 

Whenever  it  seems  desirable  to  investigate  the  condition 
of  these  organs,  we  must  first  of  all  make  some  special  in- 
quiries into  the   past  history  of  the  patient,  in  addition  to 

*  In  this  slight  sketch  of  the  subject  I  follow,  with  some  abridgment, 
the  method  of  case-takiijg  adopted  by  Professor  Simpson,  in  the  Bu- 
chanan Ward  in  the  Edinburgh  Royal  Infirmary. 


REPRODUCTIVE   SYSTEM.  22/ 

thoSe  general  points  which  have  already  been  enumerated 
in  Chapter  I.  The  most  important  of  these  are  as  fol- 
lows: 

I.  Menstruation. — In  connection  with  menstruation  we 
should  ascertain — (i)  the  date  at  which  it  first  appeared; 
(2)  the  regularity  or  irregularity  of  its  return,  and  the  in- 
terval of  time  between  the  commencement  of  one  menstrual 
period  and  that  of  the  next;  (3)  the  duration  of  each  period 
and  quantity  of  the  discharge;  (4)  the  amount  of  pelvic  or 
general  disturbance  which  accompanies  each  menstruation; 
and  (5)  the  date  of  termination,  should  the  patient  have 
ceased  to  menstruate. 

If  menstruation  has  become  abnormal,  then  we  may  have 
to  deal  with  one  of  three  conditions — amenorrhoea,  menor- 
rhagia,  or  dysmenorrhcea. 

(i.)  Amenor7'Ji«a,  or  absence  of  the  menstrual  flow,  is  a 
normal  condition  before  puberty,  after  the  menopause,  and 
during  pregnancy  and  lactation.  Apart  from  these  physio- 
logical states,  the  chief  causes  of  amenorrhoea  are  the  fol- 
lowing: 

A.  Abnormal  conditions  of  reproductive  organs. 

(^.)  Absence,  atrophy  or  rudimentary  condition  of 

uterus  and  ovaries. 
(^.)  Occlusion  of  the  uterine  or  vaginal  canal, 
(r.)  Pelvic  peritonitis. 
(^.)  Cystic  degeneration  of  both  ovaries. 

B.  Abnormal  haemic  conditions. 

(c?.)  Chlorosis. 

{b!)  Anaemia. 

[c?)  Debilitating  diseases,  as  phthisis,  etc. 
(2.)  Menorrhagia. — Under  this  term  are  included  two  con- 
ditions— first,  increase  of  the  menstrual  flow;  and,  second, 
a  flow  of  blood  from  the  uterus  during  the  intervals.  The 
latter  condition  sometimes  receives  a  special  name — metror- 
rhagia. 

Menorrhagia  may  result  from  various  abnormal  states 
of  the  system  —  plethora,  anaemia,  struma,  constipation, 
Bright's  disease,  purpura,  etc.  It  may  also  occur  as  the 
result  of  some  local  affection,  such  a  polypus,  fibrous  or 
cancerous  tumor,  degeneration  of  the  uterine  mucous  mem- 
brane, chronic  ovaritis,  etc.,  besides  the  various  conditions 
— normal  and  abnormal — in  connection  with  pregnancy, 
which  give  rise  to  hemorrhage. 


228  MEDICAL   DIAGNOSIS. 

When  a  constitutional  cause  can  be  clearly  ascertained 
no  local  examination  is  necessary,  but  when  this  is  not  the 
case  a  careful  physical  examination  should  be  made. 

(3.)  Dysffiejiorrhoea,  or  painful  menstruation,  may  result 
from  general  or  from  local  causes.  The  former  include  all 
those  general  conditions  which  predispose  to  or  excite  neu- 
ralgia, such  as  plethora,  anaemia,  malaria,  gout,  rheuma- 
tism, enervating  habits,  etc.  Of  local  causes  there  are — (i) 
congestive  and  inflammatory  conditions  of  uterus,  ovaries, 
or  pelvic  cellular  tissue;  and  (2)  such  conditions  as  lead  to 
obstruction  of  the  uterine  or  the  vaginal  canal.  Unless  a 
constitutional  cause  can  be  clearly  ascertained,  a  careful 
local  exploration  ought  to  be  made. 

2.  Leucorrhoea,  or  fluor  albus — the  white  or  yellow  inter- 
menstrual discharge  so  frequently  met  with — is  of  two  varie- 
ties, according  as  it  has  its  source  in  the  uterus  or  vagina. 
In  the  former  case  it  is  alkaline  and  in  the  latter  acid,  and 
the  vaginal  form  contains  in  much  larger  quantity  those 
flattened  and  irregularly  shaped  epithelial  cells  which  line 
that  canal.  Specular  examination  will  at  once  show  the 
source  of  the  discharge  in  question. 

3.  Pareunia. 

4.  Pregnancies. — Former  pregnancies  have  an  important 
bearing  on  uterine  disease.  It  is  well,  therefore,  to  note 
their  number,  the  date  of  the  first  as  well  as  that  of  the 
most  recent,  the  state  of  health  from  conception  to  labor, 
the  character  of  the  labors,  the  patient's  condition  during 
the  subsequent  lactation,  and  finally,  whether  she  has  had 
any  abortions. 

Local  functional  derangements  of  the  bladder,  rectum, 
etc.,  and  general  disturbances  of  other  systems,  are  consid- 
ered elsewhere  in  these  pages,  and  need  not  be  repeated 
here. 

■PHYSICAL    EXAMINATION. 

The  physical  examination  of  the  female  generative  organs 
comprises  the  following  points: 

I.  The  Mammae. — As  a  sign  of  pregnancy  the  condition 
of  the  breasts  is  of  considerable  importance.  The  chief 
points  are — enlargement    and    turgescence  of  the  nipple, 


REPRODUCTIVE   SYSTEM. 


229 


deepening  of  the  color  of  the  areola,  enlargement,  hard- 
ness, and  knotting  of  the  glands  themselves,  together  with 
the  secretion  of  milk. 

2.  The  Abdomen. — When  treating  of  the  physical  exami- 
nation of  the  abdomen,  the  diagnosis  of  uterine  and  ovarian 
tumors  was  postponed  until  we  should  come  to  consider 
the  Reproductive  System  as  a  whole. 

Ovarian  cystic  tumors  are  often  very  difficult  of  diag- 
nosis. By  the  inexperienced  such  conditions  as  obesity, 
oedema  of  the  walls  of  the  abdomen,  phantom  tumor,  or 
meteorism,  may  be  mistaken  for  ovarian  dropsy.  But  be- 
sides these  and  similar  conditions  in  which  the  resemblance 
is  somewhat  remote,  there  are  certain  diseases  which  so 
closely  resemble  ovarian  dropsy,  that  even  experienced 
practitioners  often  find  great  difficulty  in  arriving  at  a  diag- 
nosis. The  following  table  shows  the  main  points  of  diag- 
nostic difference  between  ovarian  dropsy  and  ascites  : 


Ovarian  Dropsy. 

Tumor  develops  from  one  iliac 
fossa. 

Tumor  is  more  ovoid  when  the 
patient  lies  on  her  back. 


On  percussion  the  dulness  is  cen- 
tral, the  intestines  giving  a  clear 
note  at  the  sides. 

Change  of  position  does  not  alter 
the  line  of  dulness.  , 

CEdema  of  the  feet  only  occurs  in 
the  last  stages. 


Ascites. 

No  history  of  lateral  develop- 
ment. 

The  bulging  is  at  the  flanks  when 
the  patient  lies  on  her  back,  and  the 
anterior  abdominal  surface  is  flat- 
tened. 

On  percussion  the  dulness  is  at 
the  flanks,  to  which  the  fluid  gravi- 
tates; the  centre  of  the  abdomen, 
where  the  bowels  float,  being  clear. 

Change  of  position  alters  the  line 
of  dulness  in  the  manner  already 
described. 

CEdema  of  feet  often  occurs  early 
in  the  case. 


It  occasionally  happens  that  pregnancy  is  mistaken  for 
an  ovarian  tumor.  While  all  the  ordinary  signs  and  symp- 
toms of  pregnancy  must  be  carefully  considered,  it  is  nec- 
essary to  bear  in  mind  that  morning  sickness  and  the  mam- 
mary changes  ma}^  occur  in  ovarian  disease.  Ballottement, 
the  foetal  heart  sounds,  and  the  uterine  souffle,  are  the  most 
important  diagnostic  points.  Even  the  passage  of  the  ute- 
rine sound,  and  consequent  abortion,  would  be  better  than 
the  plunging  of  a  trochar  into  the  pregnant  uterus  under 
the  belief  that   it  is  an  ovarian  cyst,  an  operation  which 


230  MEDICAL   DIAGNOSIS. 

has  been  performed  more  than  once  by  experienced  sur- 
geons. 

The  differential  diagnosis  between  ovarian  dropsy  and 
fibrocystic  tumor  of  the  uterus  is  often  a  matter  of  very 
considerable  difficulty.  Dependence  should  be  placed  upon 
the  slowness  of  the  growth  of  the  latter  disease,  and  the 
enlargement  of  the  uterine  cavity,  as  well  as  upon  the  nature 
of  the  fluid  obtained  on  tapping.  Details  will  be  found  in 
special  works  on  gynecology. 

3.  The  External  Pudenda. — The  digital  examination  of  the 
vulva  will  usually  reveal  any  morbid  condition  which  may 
exist  in  connection  with  the  labia,  the  orifice  of  the  urethra, 
the  fossa  navicularis,  the  vestibule,  and  the  perineum.  In 
this  manner  may  be  recognized,  for  example,  inflammatory 
and  suppurative  processes  in  the  labia,  urethral  caruncles, 
and,  when  the  perineum  has  become  destroyed,  prolapse  of 
the  rectal  or  the  vesical  wall,  or  of  the  uterus  itself. 

4.  Examination  per  Vaginam. — The  patient  should  be  laid 
on  a  couch  or  table  on  her  left  side,  with  the  knees  well 
drawn  up  and  the  shoulders  low.  The  index  finger  of  the 
left  hand,  previously  well  lubricated,  is  then  to  be  gently 
introduced  into  the  vagina  and  steadily  passed  upward  to 
the  OS  uteri.  In  this  way  information  regarding  the  vulva 
and  the  vaginal  walls  will  be  obtained;  and  now  the  os  and 
cervix  may  be  carefully  examined  as  to  size,  consistency, 
etc.,  and  the  finger  or  fingers  (for  it  is  sometimes  advisable 
to  introduce  two)  may  be  passed  into  the  recto-uterine 
space,  and  finally  swept  along  the  roof  of  the  cavity  to  the 
symphysis  pubis.  In  this  manner  much  may  be  learned  as 
to  the  condition  of  the  cervix  and  os,  the  position  of  the 
body  of  the  uterus  (retro-  and  ante-flexion  and  version), 
and  the  condition  of  the  rectum,  peritoneal  sac,  cellular 
tissue  round  the  uterus,  the  bladder,  etc. 

Vaginal  examinations  should  not  be  made  in  the  case  of 
unmarried  women,  unless  the  symptoms  are  severe. 

5.  Bimanual  Examination. — Much  more  important  than 
the  ordinary  vaginal  examination  is  the  bimanual  examina- 
tion, of  which  there  are  several  varieties.  While  the  fingers 
of  one  hand  remain  in  the  vagina,  the  other  hand  of  the 
physician  is  used  to  bring  the  pelvic  organs  more  fully 
within  reach.     The  most  usual  position  of  the  second  hand 


REPRODUCTIVE    SYSTEM.  23 1 

is  on  the  anterior  abdominal  wall  (abdomino-vaginal  ex- 
amination), the  patient  being  made  to  lie  on  her  back. 
Sometimes,  however,  the  fingers  may  be  passed  into  the 
rectum,  while  those  of  the  other  hand  are  in  the  vagina 
(recto-vaginal  examination).  At  other  times  the  passage 
of  a  sound  into  the  bladder  may  be  combined  with  vaginal 
and  rectal  palpation. 

All  the  various  possible  varieties  of  this  combined  method 
place  within  our  power  a  very  complete  examination  of  the 
pelvic  organs.  The  uterus  may  be  carefully  palpated  on 
all  its  surfaces,  and  its  size,  shape,  and  position  clearly  de- 
fined. Its  consistence,  sensitiveness,  and  mobility  may 
also  be  ascertained.  We  may  also  thus  learn  the  condi- 
tion of  the  ovaries  and  fallopian  tubes,  and  generally  that 
of  all  the  organs  and  important  tissues  contained  within 
the  pelvis. 

6.  The  Speculum  is  much  more  useful  to  aid  in  treatment 
than  in  diagnosis.  Its  diagnostic  value  is  confined  to  the 
inspection  of  the  os  and  cervix  and  of  the  vaginal  walls, 
which  it  allows  of.  Of  the  many  varieties  of  this  intru- 
ment  which  have  been  devised,  the  most  useful  are  the 
cylindrical  speculum  of  Fergusson,  the  bivalve  of  Cusco, 
and  the  duck-bill  speculum  of  Sims.  In  using  the  two 
former  instruments  the  ordinary  lateral  position  usually 
suffices.  The  Sims  speculum  can  only  be  advantageously 
used  when  the  patient  is  placed  in  a  special  position,  which 
is  neither  on  left  side  nor  on  the  face,  but  in  a  position  be- 
tween the  two,  the  left  arm  being  drawn  out  behind  her, 
and  the  knees  flexed — the  right  lying  above  the  left.  The 
Sims  speculum  requires  to  be  held  by  an  assistant.  What- 
ever form  of  instrumeut  be  used  it  must  be  carefully 
warmed  and  oiled  before  introduction. 

7.  The  Uterine  Sound  is  an  important  aid  to  diagnosis. 
By  its  means  we  learn  the  size  and  mobility  of  the  uterus, 
and  the  direction  of  the  uterine  cavity.  The  best  variety 
of  instrument  is  that  devised  by  Sir  James  Simpson,  more 
especially  the  modified  form  which  Professor  A.  R.  Simpson 
has  recently  recommended.  The  physician  touching  the  os 
uteri  with  tw^o  fingers  of  the  right  hand,  grasps  the  handle 
of  the  sound  in  the  left,  and  passes  the  point  of  the  instru- 
ment into  the  vagina,  in  close  apposition  to  his  finger,  and 
thus  guides  it  into  the  external  os.    If  the  uterus  be  normal 


232  MEDICAL  DIAGNOSIS. 

in  position,  the  handle  of  the  sound  must  now  be  moved 
round  in  a  wide  semicircle,  so  as  to  make  the  point  look 
forward.  The  instrument  will  then  glide  into  the  uterine 
cavity.  If,  however,  the  uterus  be  retroverted  this  rota- 
tion will  not  be  required.  No  force  must  be  used  in  pass- 
ing the  sound. 

Any  displacement  which  exists  will  at  once  be  recognized 
by  the  course  which  the  sound  takes,  and  the  length  of  the 
uterine  cavity  can  be  gauged  by  noting  how  far  the  sound 
enters.  To  render  this  measurement  more  easy  the  in- 
strument is  marked  at  different  distances  from  the  point. 
At  2^  inches  (the  normal  length  of  the  cavity)  the  sound 
presents  a  knob  or  ring,  which  is  readily  recognized  by 
the  finger  in  the  vagina;  at  3^  inches  there  is  a  notch;  at 
4y  inches  a  double  knob  or  ring ;  at  5^  a  notch,  and 
so  on. 

The  uterine  sound  must  not  be  introduced  during  a 
menstrual  period,  or  when  there  is  any  suspicion  of 
pregnancy,  any  inflammation  of  the  uterus  or  in  its  neigh- 
borhood, or  in  cases  of  cancer  of  the  cervix  or  body  of  the 
uterus. 

8.  Instruments  for  Dilating  the  Cervix. — Of  these  the  most 
important  are  the  various  forms  of  tent.  These  instru- 
ments dilate  the  cervical  canal,  so  as  to  allow  the  finger  to 
pass  into  and  to  explore  the  uterine  cavity.  They  are 
made  of  sponge,  of  sea-tangle,  or  of  the  wood  of  the  tupelo 
or  nyssa  tree.  The  sponge  tents  expand  more  rapidly  than 
either  of  the  other  kinds,  but  they  are  apt  to  induce  fetor. 
The  variety  of  tent  which  is  to  be  selected  in  any  given 
case  depends  upon  the  size  of  the  cervical  canal  and  the 
rapidity  with  which  we  wish  dilatation  to  take  place.  The 
tent  is  most  easily  introduced  through  a  speculum.  The 
vagina  should  first  of  all  be  washed  out  with  some  anti- 
septic lotion,  and  then  the  tent,  held  in  a  pair  of  dressing 
forceps,  gently  introduced  into  the  cervix.  The  tent  should 
be  lubricated  with  carbolized  vaselin,  and  after  it  is  in  its 
place  some  carbolized  cotton  wool  should  be  introduced 
into  the  vagina  and  packed  up  to  the  cervix.  The  tent 
should  not  be  allowed  to  remain  in  the  uterus  after  it  has 
reached  its  full  expansion,  and  in  no  case  longer  than 
twenty-four  hours.  After  the  introduction  of  the  instru- 
ment the  patient  should  be  strictly  confined  to  bed,  and 
she   should    retain   the   recumbent    posture    for  at   least 


NERVOUS  SYSTEM.  233 

twenty-four  hours  after  its  removal.  Tents  must  not  be 
employed  when  there  is  pelvic  inflammation  of  any  sort. 

The  cervical  canal  may  also  be  dilated  by  passing  into  it 
a  graduated  series  of  metallic  bougies,  or,  better,  by  the 
use  of  Molesworth's  dilators,  which  consist  of  elongated 
bags  of  india-rubber,  into  which  air  or  water  can  be  forced 
by  means  of  a  powerful  syringe. 

Beside  these  methods  of  physical  examination  which 
have  just  been  enumerated,  it  is  necessary  to  mention  the 
curette,  by  which  a  small  piece  of  a  tumor  can  be  removed 
for  microscopic  examination;  and  the  aspiratory  needle, 
by  which  we  can  obtain  a  specimen  of  the  contents  of  a 
doubtful  cysto 


CHAPTER  XXVII. 

Nervous  System, 
sensory  functions. 


The  diseases  of  the  nervous  system  are  so  complicated, 
and  at  the  same  time  their  diagnosis  is  now  becoming  in 
the  majority  of  cases  so  precise,  as  a  strict  logical  deduc- 
tion from  the  signs  and  symptoms  observed  at  the  bedside, 
that  very  special  attention  must  be  paid  to  the  systematic 
arrangement  of  the  inquiries  which  the  physician  has  to 
make,  and  to  the  methods  to  be  employed  in  testing  the 
condition  of  the  various  functions  of  the  nervous  apparatus. 

These  functions  will  be  considered  in  the  following  order  : 

1.  Sensory  Functions. 

2.  Motor  Functions. 

3.  Vaso-motor  Functions. 

4.  Trophic  Functions. 

5.  Cerebral  and  Mental  Functions. 

6.  Condition  of  Cranium  and  Spine, 


SENSORY    FUNCTIONS. 


The  phenomena  met  with  in  connection  with  the  sensory 
apparatus  are  of  two  kinds  ;  firstly,  subjective^  i.  <f.,  such  sen- 


234  MEDICAL  DIAGNOSIS. 

sations  as  arise  independently  of  any  external  irritation  ; 
and,  secondly,  objective,  i.e.,  sensibility  to  external  stimula- 
tion of  various  kinds.  Although  this  classification  is  open 
to  considerable  criticism,  it  will  be  found  to  be  convenient 
for  purposes  of  description,  and  for  clinical  examination. 

Subjective  Sensations. — Among  the  many  sensations  of 
which  patients  complain,  the  following  are  the  most  impor- 
tant : — 

I.  Fain.'^ — Pain  is  simply  an  exaggeration  of  common 
sensibility.  It  is  often  the  result  of  inflammation  or  other 
local  disease  of  the  tissues.  When  the  pain  is  intermittent, 
darting,  and  occurs  suddenly,  following  the  course  of  some 
nerve  and  its  branches,  it  is  termed  iieuralgia.  Of  the  many 
forms  of  neuralgia,  the  most  commonly  encountered  are — 

{a?)  Tic  Douloureux,  neuralgia  of  the  fifth  nerve,  which 
consists  of  paroxysms  of  pain  corresponding  in  site  to  the 
nerve  and  its  branches  on  the  face. 

(^.)  Intercostal  Neuralgia  is,  as  its  name  implies,  an  affec- 
tion of  the  intercostal  nerves.  It  is  to  be  carefully  distin- 
guished from  the  pain  of  pleurisy  and  of  muscular  rheu- 
matism. 

(^.)  Sciatica. — The  pain  here  corresponds  to  the  course  of 
the  sciatic  nerve  and  its  branches.  It  is  usually  localized 
between  the  tuber  ischii  and  the  great  trochanter,  and  shoots 
downward,  sometimes  as  far  as  the  heel. 

(^.)  Visceral  Neuralgice. — These  pains  may  be  referred  to 
the  region  of  the  heart  and  aorta  (angina  pectoris),  of  the 
stomach,  intestines,  liver,  kidneys,  uterus,  or  ovaries. 

It  was  first  pointed  out  by  Valleix  that,  when  the  nerve 
which  is  affected  with  neuralgia  lies  superficially,  there  can 
be  found  during  an  attack  certain  points  upon  the  skin, 
which  are  painful  on  pressure.  '  Such  painful  points  are 
usually  situated  where  the  nerve  leaves  an  osseous  canal  or 
comes  thfough  a  strong  fascia. 

Beside  these  neuralgiae  there  are  various  painful  sensa- 
tions which  are  met  with  in  nervous  diseases,  and  which 
must  be  looked  for  in  such  cases.   Of  these  we  may  notice — 

{a?)  Girdle  Pai7i,  which  is  the  sensation  of  having  a  cord 
or  girdle  tied  tightly  round  the  body.      It  may  be  felt  at 

*  Many  of  the  varieties  of  pain  mentioned  are  not  subjective,  arising 
as  they  do  from  local  causes,  but  they  are  classified  here  because  they 
occur  without  any  stimulation  of  the  sensory  apparatus  on  the  part  of 
the  physician. 


NERVOUS   SYSTEM.  235 

various  levels,  on  the  thorax,  abdomen,  or  on  the  lower  ex- 
tremities at  the  knee  or  ankle.  It  is  commonly  met  with  in 
connection  with  inflammatory  and  degeneration  changes  in 
the  cord,  and  is  believed  to  result  from  slight  excitation  of 
the  posterior  nerve-roots. 

(l?.)  Lightning  Paifis. — Among  the  most  common  symptoms 
in  locomotor  ataxia,  are  paroxysms  of  darting,  lancinating 
pains,  which  shoot  through  the  body,  and  which  have  re- 
ceived the  name  of  lightning  pains. 

(<:.)  Headache  in  all  its  many  forms.  Headache  arises 
from  a  great  variety  of  morbid  conditions,  such  as  vaso- 
motor changes  within  the  cranium,  abnormal  composition 
of  the  blood,  organic  disease  of  the  cranium  or  scalp,  or  of 
the  brain  or  its  membranes.  The  differential  diagnosis  of 
these  different  forms  is  to  be  found  in  special  works  on  the 
subject.  It  is  sufficient  now  to  point  out  that  the  mode  of 
invasion,  the  intensity,  and  the  site  of  the  headache  must  be 
exactly  ascertained,  as  well  as  the  presence  of  any  obvious 
exciting  cause. 

2.  ParcBsthesice,  or  perverted  sensations,  are  commonly 
met  with  among  disorders  of  th^  nervous  system. 

{a?)  Sensations  of  Heat  and  Cold  (independently  of  actual 
elevation  or  depression  of  temperature)  are  met  with  in  in- 
termittent fever,  and  also  in  various  nervous  diseases. 

(^.)  Nicmbness. — Any  condition  tending  to  depress  the 
activity  of  the  cutaneous  sensibility  may  give  rise  to  sensa- 
tions of  this  kind,  where  the  patient  feels  as  if  he  were  walk- 
ing on  a  soft  carpet,  and  has  a  tingling  sensation  up  the 
limbs.     It  may  also  take  the  form  of — 

(r.)  Fornication,  or  the  sensation  of  ants  crawling  over  the 
skin.  These  two  forms  of  paraesthesia  are  caused  by  affec- 
tions of  the  nerve  trunk  (cold,  mechanical  injuries,  etc.),  or 
of  the  central  organs  (locomotor  ataxia,  hysteria,  etc.),  but 
probably  not  of  the  peripheral  terminations. 

(d.)  Pruritus,  or  itching,  is  caused  by  disease  or  irritation  of 
the  terminal  end  organs  in  the  papillae  of  the  skin.  It  arises 
as  a  result  of — 

(«.)  Many  skin  diseases,  particularly  the  parasitic  va- 
rieties. 
(^.)   Prurigo. 

(c!)  Various  chemical  substances  circulating  in  the 
blood — bile,  sugar,  hippuric  acid,  and  perhaps 
xanthin  and  creatin  (Eulenburg). 

3.  Giddiness  {Vertigo),  is  a  sensation  of  swimming  in  the 


236  MEDICAL  DIAGNOSIS. 

head,  the  body  appearing  to  oscillate  in  different  directions, 
and  surrounding  objects  to  rotate,  and  is  accompanied  with 
reeling  and  staggering.  In  Meniere's  disease  (auditory  ver- 
tigo), and  in  disease  of  the  cerebellum,  vertigo  is  a  frequent 
symptom  ;  but  it  also  arises  from  any  condition  which  dis- 
turbs the  circulation  in  the  cranium,  such  as  dyspepsia, 
heart  disease,  mental  work,  etc.,  etc.  In  many  cases  ver- 
tigo arises  from  a  contradiction  between  the  impressions  of 
external  relations  derived  from  two  or  more  special  senses. 

4.  Abfiormal  Visceral  Sensations, — These  comprise  such  sen- 
sory disturbances  as  pyrosis  or  water  brash,  boulimia  or  ab- 
normal hunger,  polydipsia  or  excessive  thirst,  and  certain 
other  similar  symptoms. 

Such  are  the  more  important  of  the  abnormal  sensations 
complained  of  by  patients  suffering  from  nervous  disorders. 
We  now  turn  to  what  is  of  much  greater  value  in  diagno- 
sis, in  that  it  admits  of  precise  determination — viz.,  the  ac- 
tual condition  of  the  cutaneous  sensibility  as  tested  by  the 
physician  himself. 

Cutaneous  sensibility  is  of  two  kinds — 

(i.)  Co7?imon  or  General  Sensation^  which  includes  the  con- 
sciousness of  contact  with  a  substance  which,  when  exagger- 
ated, amounts  to  pain  ;  and 

(2)  Tactile  Sens ati 071,  comprehending — 
(^.)  Sensations  of  pressure. 
(^.)  "  "  temperature. 

\c!)  "  "  locality. 

These  will  each  be  considered  in  turn. 

1.  Common  Cutaneous  Sensibility  may  be  tested  by  means 
of  touching,  tickling,  pinching,  or  pricking  the  skin.  All 
these  methods  of  stimulation  give  indications,  but  by  far 
the  most  accurate  results,  as  Duchenne  first  showed,  are 
obtained  by  using  the  Faradic  current.  The  strength  of 
the  current  may  be  varied  from  that  just  sufficient  to  cause 
a  perceptible  sensation  up  to  one  which  produces  sharp 
pain.  By  comparing  the  minimum  strength  of  current  re- 
quired to  cause  a  sensation  at  different  parts  of  the  body, 
important  indications  may  be  obtained. 

2.  Tactile  Sensibility  includes  sensations  of  pressure,  tem- 
perature, and  locality. 

(a.)  The  Seiise  of  Pressure  is  best  tested  by  the  method 
devised  by  E.  H.  Weber,  which  consists  in  the  application 


NERVOUS  SYSTEM.  237 

of  different  weights  over  the  portion  of  skin  to  be  exam- 
ined. In  order  to  eliminate  the  muscular  sense  it  is  neces- 
sary to  lay  the  hand  or  foot,  as  the  case  may  be,  upon  a 
firm  support,  and  further,  it  is  advisable  to  interpose  some 
non-conducting  substance,  so  as  to  prevent  the  temperature 
or  size  of  the  weight  from  being  recognized,  as  these  im- 
pressions might  give  some  indication  of  its  weight.  Other 
methods  have  been  devised,  but  for  all  ordinary  purposes 
that  described  is  the  simplest  and  best. 

{^.)  The  Sense  of  Temperature  is  tested  by  applying  to  the 
skin  two  bodies  of  unequal  temperature,  the  most  conve- 
nient being  two  test-tubes,  one  filled  with  cold,  the  other 
with  hot  water.  The  most  sensitive  parts  of  the  body  are 
the  skin  of  the  face  and  of  the  back  of  the  hands  (Weber), 
where  differences  of  temperature  of  0.3  C.  can  readily  be 
distinguished.  A  difference  equal  to  a  degree  of  the  centi- 
grade scale  can  be  appreciated  at  any  part  of  the  body. 

(<:.)  The  Sense  of  Locality  is  to  be  tested  by  pinching  some 
portion  of  the  patient's  body  when  his  eyes  are  closed,  and 
making  him  indicate  the  site  of  the  touch.  In  health  the 
error  is  very  small  indeed.  It  may  further  be  tested  by  as- 
certaining to  what  distance  the  two  points  of  a  pair  of  com- 
passes, or  of  Sieveking's  aesthesiometer,  pressed  upon  the 
skin,  must  be  separated  before  they  can  be  recognized  by 
the  patient  as  distinct.  Weber  gives  the  following  as  the 
minimum  distances  to  which  the  points  must  be  separated, 
to  be  felt  as  different  points,  in  health: — 
On  the  point  of  the  tongue 1.18  m.m. 

"        palmar  surface  of  last  phalanx  of  finger.. 2. 25  m.m. 

2d  ''  "        ..4.5     m.m. 

"        plantar       "  last        "       great  toe,  11.25  rn-rn 

"        back  of  the  hand 31.5  m.m. 

"        forearm,  and  leg,  and  dorsum  of  foot.  ..40.5  m.m. 

"        upper  arm  and  thigh 77.5  m.m. 

(i  m.m.  =  0.039  irich.) 
In  disease  all  these  various  forms  of  cutaneous  sensibil- 
ity may  be  affected,  either  diminished   (anaesthesia)  or  ren- 
dered more  acute  (hypersesthesia),  and  they  may  be  either 
collectively  or  individually  affected. 

When  sensibility  to  pain  is  diminished,  the  condition  is 
named  analgesia,  and  when  it  is  increased,  hyperalgesia.  In 
the  same  way,  we  speak  of  therino-ancEsthesia  and  thermo- 
hyper (Esthesia,  when  the  sensibility  to  heat  is  diminished  or 
increased;  and  other  refinements  of  nomenclature  have  been 


238  MEDICAL   DIAGNOSIS. 

devised  by  Eulenburg,  such  as  apselaphesia  and  hype7'psela- 
pkesia,  referring  to  tactile  sensibility  alone,  the  former  indi- 
cating a  decrease  and  the  latter  an  increase.  All  these  par- 
tial affections  of  the  cutaneous  sensibility  are  most  fre- 
quently met  with  in  cases  of  locomotor  ataxia. 

Finally,  we  have  to  note  the  rapidity  of  the  conduction 
of  these  cutaneous  sensory  impressions  to  the  brain.  In 
health  this  takes  place  in  a  little  over  .1  second;  and  it  is 
often  easy — in  the  case  of  locomotor  ataxia,  for  example — 
to  observe  an  abnormal  prolongation  of  this  period.  It  is 
not  uncommon  to  notice  in  such  patients  that  the  tactile 
and  painful  impressions  do  not  travel  at  the  same  rate  of 
speed,  the  prick  of  a  needle  being  instantaneously  felt  as  a 
touch,  and,  after  an  interval  of  a  few  seconds,  as  a  painful 
sensation. 

Muscular  Sense  * — that  collection  of  impressions  by  means 
of  which  the  mind  is  enabled  to  appreciate  the  degree  of 
contraction  of  the  muscles — demands  careful  investigation, 
since  its  presence  or  absence  in  a  particular  case  is  of  great 
diagnostic  significance.  It  is  tested  by  causing  the  patient 
to  lift  various  weights  (suspended  in  a  towel,  so  as  to  elim- 
inate as  far  as  may  be  the  cutaneous  sensibility  to  pressure), 
and  we  may  either  determine  the  smallest  weight  which  can 
be  appreciated  as  such,  or  the  smallest  difference  between 
two  weights  which  he  can  perceive.  The  muscular  sense 
may  also  be  tested  by  asking  the  patient,  with  closed  eyes, 
to  point  to  or  to  touch  some  particular  part  of  the  body, 
such  as  the  tip  of  the  nose  or  ear,  or  the  great  toe.  The 
absence  of  this  sense  is  frequently  associated  with  loss  of 
equilibrium  of  the  body. 

We  now  pass  to  the  consideration  of  the  special  senses. 

SIGHT. 

For  a  full  description  of  the  various  affections  of  sight, 
special  works  on  the  subject  must  be  consulted.  A  very 
brief  outline  may,  however,  here  be  given  of  the  alterations 
which  arise  as  the  result  of  nervous  affections,  it  being  dis- 
tinctly understood  that  all  defects  of  vision  caused  by  ab- 
normalities in  the  refracting  media  are  excluded  from  con- 
sideration. 

Optic  Hyperesthesia  and  Hype7-algesia,  the  increase  of  the 

*  The  common  sensibility  of  the  muscles  is  not  here  alluded  to,  as  be- 
ing of  minor  importance  and  possessing  little  diagnostic  significance. 


NERVOUS  SYSTEM.  239 

retinal  sensibility — amounting  to  a  painful  sensation,  with 
intolerance  of  light — is  common  in  meningitis  and  in  cere- 
bral hyperaemia,  and  illusions  of  sight  often  occur  in  insan- 
ity, dependent  upon  central  changes.  The  most  frequent 
pathological  condition,  however,  is 

Optic  Atuesthesia,  the  diminution  or  total  loss  of  vision. 
When  (from  nervous  causes)  the  sight  is  merely  impaired, 
we  speak  of  afnblyopiaj  when  it  is  entirely  lost,  of  amaurosis. 

In  amblyopia  the  vision  may  be  affected  as  regards  acute- 
ness,  extent,  or  color. 

1.  Di77iimction  in  Visual  Acuteness  causes  the  objects  seen 
to  appear  blurred,  misty,  and  indistinct.  The  most  usual 
method  of  testing  the  acuteness  of  vision  is  by  means  of 
test  types,  which  the  patient  is  made  to  read  at  a  distance. 
Defective  vision  may  be  merely  functional,  resulting  from 
debility,  gastric  and  uterine  affections,  abuse  of  tobacco, 
etc.,  when  no  abnormal  ophthalmoscopic  appearances  pre- 
sent themselves;  or  it  maybe  due  to  optic  neuritis  or  retin- 
itis, or  to  atrophy  of  the  optic  nerve. 

2.  AUe7'atio7is  in  the  extent  of  the  Visual  Field  ^x^  most  accu- 
rately determined  by  means  of  the  perimeter,  but,  for  all 
ordinary  purposes,  it  is  only  necessary  to  stand  opposite  to 
and  near  the  patient,  who  should  be  directed  to  shut  one 
eye  and  to  fix  the  other  steadily  on  that  of  the  operator. 
The  latter  should  then  move  his  hand  in  every  direction, 
and. ascertain  at  what  points  it  enters  the  visual  field.  Any 
deviation  from  the  normal  condition  can  be  thus  readily 
detected.  The  visual  field  ma}"  be  encroached  upon  either 
from  the  centre  or  from  the  margin.  In  the  former  case  a 
dark  spot  (scotoma)  forms  in  the  centre  and  gradually  en- 
larges. The  scotoma  may  be  steady,  or  scintillating,  zig- 
zag, and  brightly  colored,  as  in  migraine.  Such  limitations 
of  the  field  of  vision  are  met  with  in  functional  amblyopia 
(especially  from  abuse  of  tobacco),  in  optic  neuritis,  and  in 
optic  atrophy. 

The  field  of  vision  may  further  be  abolished  as  regards 
one  lateral  half  of  the  retinae  (hemiopia),  the  vertical  line 
of  demarcation  being  very  sharply  defined.  This  affection 
of  vision  is  characteristic  of  disease  of  the  optic  tracts  and 
commissure.  The  exact  localization  of  the  lesion  can  be 
deduced  from  the  anatomical  arrangement  of  the  nerve 
fibres  in  the  tracts  and  commissures,  but  for  details  special 
works  must  be  consulted.* 

*  In  particular,  Charcot's  "  Le5ons  sur  la  Localisation  des  Maladies  dii 
Cerveau." 


240  MEDICAL  DIAGNOSIS. 

3,  Alterations  in  the  Perception  of  Colors. — To  test  the  per- 
ception of  color,  a  scale  of  colors  as  those  of  the  spectrum 
should  be  employed,  and  the  patient  should  be  called  upon 
to  name  them  when  presented  to  him.  Color-blind  persons 
cannot  distinguish  red.  The  visual  field  for  the  perception 
of  colors  may  also  be  encroached  upon.  In  health  it  is  to 
be  noted  that  the  area  of  vision  differs  in  the  case  of  each 
color,  being  greatest  for  white — next  yellow,  then  blue, 
red,  and,  last  of  all,  green. 

Movements  of  the  Eyeball.* 

The  ocular  muscles  are  supplied  by  three  nerves — the 
oculo-motorius,  or  3d  nerve;  the  trochlearis,  or  4th  nerve; 
and  the  abducens,  or  6th  nerve.  Spasm  and  paralysis  of 
each  of  these  affect  the  muscles  which  they  supply,  and 
produce  corresponding  changes  in  the  position  of  the  eye- 
ball. Their  action  on  the  pupil  will  be  subsequently  con- 
sidered. 

I.    Paralysis  of  the  Ocular  Nerves. 

(i.)  Oculo-motorius^  or  T^d  Nerve. — According  as  the  para- 
lysis is  complete  or  incomplete,  the  whole,  or  only  one  or 
more  of  the  following  muscles  are  affected: 

{a?)  Levator  Palpebrce  Superioris. — Paralysis  causes  droop- 
ing of  the  upper  eye-lid — ptosis. 

{b?)  Superior  Rectus. — The  eyeball  turns  downwards  and 
slightly  outwards  when  this  nerve  is  paralyzed,  and 
there  is  in  consequence  diplopia  or  double  vision,  the 
result  of  the  visual  axis  of  the  two  eyes  not  being  di- 
rected to  the  same  object.  As  this  divergence  does 
not  exist  when  the  eyeballs  are  both  turned  down- 
wards, the  patient  instinctively  carries  the  head  well 
thrown  back. 

{c).  Internal  Rectus. — ^Paralysis  here  gives  rise  to  diver- 
gent strabismus  (squint),  with  diplopia,  the  eyeball 
being  rotated  outwards  on  account  of  the  unopposed 
action  of  the  external  rectus. 

(^.)  Inferior  Rectus. — The  affected  eye  is,  in  paralysis  of 
this  muscle,  directed  upwards  and  slightly  outwards, 

*  Strictly  speaking,  these  ought  to  be  considered  among  the  motor 
functions,  but  for  convenience  they  are  introduced  here. 


NERVOUS   SYSTEM.  241 

and  there  is  diplopia  except  when    the    object  lies 
above  the  level  of  the  eyes. 
((?.)  Inferior  Oblique. — In  paralysis  of  this  muscle  the  eye- 
ball is  turned  slightly  downwards   and  inwards,  but 
this  condition  is  rarely  observed,  as  paralysis  of  the 
the  inferior  oblique  as  an  isolated  affection  is  exceed- 
ingly uncommon. 
(/.)   Ciliary  Muscle. — The  effect  of  paralysis  of  this  muscle 
is  that  the  patient  is  unable  to  change  the  convexity 
of  the  anterior  surface  of  the  lens,  or,  in  other  words, 
to  focus  his  eye  for  near  objects. 
When  the  3d  nerve  is  paralyzed  as  a  whole  all  these  ac- 
tions combine,  and  the  result  is  that  the  lid  droops,  the  eye- 
ball   is    drawn  downwards    and   outwards,   and   protrudes 
from  its  socket,  the  pupil  (as  we  shall  presently  see)  is  di- 
lated and  immobile,  and  there  is  defective  power  of  accom- 
modation. 

(2.)  Nervus  Trochlearis,  or  4th  Nerve,  supplies  the  superior 
oblique  muscle,  and  when  that  is  paralyzed  there  is  diplopia, 
the  field  of  vision  being  moved  downwards  and  outwards. 

(3.)  Nervus  Abducens,  or  6th  Nerve,  supplies  the  external 
rectus,  paralysis  of  which  causes  convergent  strabismus, 
with  consequent  diplopia,  there  being  no  power  of  rotating 
the  eyeball  outwards  beyond  the  middle  line.  This  condi- 
tion frequently  gives  rise  to  giddiness,  nausea,  and  vomit- 
ing. 

Paralysis  of  the  ocular  nerves  may  be  either  central  or 
peripheral.  In  the  latter  case  the  paralysis  is  usually  more 
complete.  Ocular  paralysis  is  common  in  locomotor 
ataxia,  syphilis,  hemiplegia,  etc.,  and  after  diphtheria. 

II. — Spasm  of  the  Ocular  Nerves.* 

( I . )    The  3  d  Nerve — 

(a.)  Levator  Palpebrce  Superioris. — Tonic  spasm  of  this 
muscle  causes  the  eyelid  to  be  drawn  up,  and  the 
eye  cannot  therefore  be  closed.  It  results  either 
from  peripheral  irritation  (rheumatism,  wound,  etc.), 
or,  reflexly,  from  irritation  of  the  sensory  fibres  of 
the  5th  nerve,  or  is  due  to  central  causes.  Clonic 
spasm  hardly  ever  occurs  in  this  muscle. 

*  Muscular  spasm  is  of  two  kinds — (i.)  Tonic,  when  the  contraction 
remains  of  nearly  uniform  intensity  while  the  spasm  lasts;  and  (2.) 
Clonic,  when  there  is  a  condition  of  rapidly  alternating  contraction  and 
relaxation. 


242  MEDICAL   DIAGNOSIS. 

(^.)  Internal  Rectus. — Of  all  the  muscles  of  the  eyeball  this 
is   the  most  frequently  affected   with    tonic  spasm. 
There  is  then  convergent  strabismus  with  diplopia, 
in  which  the  two  images  are  not  at  a  fixed  distance 
from  each  other  (as  in  squint  from  paralysis  of  the 
6th  nerve),  but  undergo  a  constant  oscillation,  alter- 
nately approaching  and  receding  from  one  another. 
(2.)    The  6th  Nerve. — Tonic  spasm  of   the  external  rectus 
is   rarely  met  with  without  implication  of  other  muscles. 
When  present  the  eyeball  is  drawn  outwards,  giving  rise  to 
divergent  strabismus. 

Clonic  Spasm  of  the  muscles  of  the  eyeball  generally  gives 
rise  to  a  condition  named  Nystagmus,  when  the  eyeball  un- 
dergoes continuous  oscillatory  and  rotatory  movements 
which  cannot  be  controlled  by  the  will.  It  arises  either 
from  local  abnormalities  of  the  ocular  structures,  or  from 
central  nervous  affections,  such  as  locomotor  ataxia,  insular 
sclerosis,  meningitis,  hydrocephalus,  etc.  Coal-miners  are 
frequently  affected  with  nystagmus,  owing  to  the  con- 
strained position  and  bad  light  in  which  they  have  to 
work.  In  them  the  nystagmus  is  probably  strictly  analo- 
gous to  writer's  cramp  in  clerks,  and  to  trade  spasms  gen- 
erally. 

Changes  in  the  Pupil. 

The  iris  being  under  the  control  of  two  mechanisms,  the 
one  reflex  (contracting) — the  afferent  fibres  lying  in  the 
optic  nerve,  the  efferent  in  the  3d  nerve,  and  the  centre  in 
the  corpora  quadrigemina;  and  the  other  a  dilating  me- 
chanism— the  efferent  fibres  being  in  the  sympathetic  and 
the  centre  in  the  cilio-spinal  region  of  the  cord  (lower  cer- 
vical and  upper  dorsal);  so  spasm  or  paralysis  of  any  of 
these  structures  will  give  rise  to  changes  in  the  size  of  the 
pupils.  There  is  probably,  however,  a  third  mechanism — 
viz.,  a  local  centre  for  the  movements  of  the  iris,  lying  either 
in  the  iris  itself  or  in  the  neighboring  choroid,  and  on  this 
mechanism  act  various  drugs  when  dropped  on  the  con- 
junctiva, such  as  atropin  (dilating)  and  physostigmin  (con- 
tracting). 

The  most  common  causes  of  change  in  the  pupils  are  ^s 
follows: 

Contraction  (myosis)  occurs  normally  when  the  eye  is  ac- 
commodated for  near  objects,  when  the  optic  nerve  or 
retina  is  stimulated,  when   the  eyeball   is  turned  inwards, 


NERVOUS   SYSTEM.  243 

•-.■»,  ^  ' 

when  the  aqueous  humor  is  defective,  and  under  the  influ- 
ence of  various  drugs — morphia,  physostigmin,  etc.  It  may, 
further,  be  due  to  disease  of  the  retina,  or  to  irritation  of 
the  3d  nerve  in  its  course,  or  of  the  higher  nerve  centres, 
to  paralysis  of  the  sympathetic,  or  to  disease  of  the  cilio- 
spinal  region  of  the  cord. 

Dilatation. — Paralysis  of  the  3d  nerve  gives  rise  to  dilata- 
tion of  the  pupil,  and  no  movements  of  the  iris  are  caused 
by  exposure  to  light  or  by  efforts  at  accommodation.  Irri- 
tation of  the  sympathetic  or  of  the  cilio-spinal  region  may 
also  cause  dilatation  of  the  pupil.  Total  paralysis  of  the 
iris  may  probably  arise  from  disease  of  the  lenticular  gan- 
glion (Hutchinson). 

Ifippus,  or  clonic  spasm  of  the  iris,  shows  itself  in  quickly 
alternating  contraction  and  dilation  of  the  pupil.  It  is 
sometimes  seen  in  cases  of  paralysis  of  the  3d  nerve,  and 
probably  in  disease  of  the  sympathetic. 

Argyle-Robertson  Symptom  consists  in  the  absence  in  the 
pupil  of  any  response  when  the  retina  is  stimulated  by 
light,  while  at  the  same  time  it  moves  normally  when  ac- 
commodation is  made.  This  condition  is  frequently  met 
with  in  locomotor  ataxia. 

Ophthalmoscopic  Exa7?iination  should  be  practised  by  every 
student  as  frequently  as  possible,  and  should  be  a  matter 
of  routine  in  the  examination  of  all  nervous  cases.  Both 
the  direct  and  the  indirect  methods  should  be  used.  When 
the  fundus  has  been  brought  into  view,  we  have  to  consider 
the  condition  of  {a)  the  retinal  vessels,  {J?)  the  optic  nerve, 
(<r)  the  retina,  and  {d)  the  choroid. 

(^.)  Reti7ial  Vessels.* — Note  the  size  and  arrangement  of 
veins  and  arteries,  and  observe  whether  there  be  visible  ar- 
terial pulsation  (in  cupping  of  the  disc  and  in  aortic  in- 
competence), anaemia,  hyperaemia,  or  hem(*>rrhages. 

ip.)    The  Optic  Nerve. — Of  abnormalities  there  may  be — 
(i.)  Simple  Co?igestioft  of  the  Disc — Vascularity;  edges  ill 

defined. 
(2.)   CEdematous  Congestion  of  the  Disc — Disc  red;  swol- 
len; edges  obscured. 
(3.)  Neuritis — Increased  redness  and  swelling;  the  edges 
of  the  disc  totally  obscured. 

*  The  arrangement  of  the  morbid  appearance  of  the  fundus  oculi  here 
given  corresponds  pretty  closely  to  that  adopted  by  Dr.  Gowers  in  hig 
work  on  "  Medical  Ophthalmoscopy." 


244  •  MEDICAL  DIAGNOSIS. 

(4.)  Atrophy — Disc  white  or  gray;  may  be  simple  or 
secondary  to  congestion  or  to  neuritis. 

(r.)  The  Retina. — The  chief  abnormalities  to  be  detected 
by  the  ophthalmoscope  are  hemorrhages,  white  spots,  and 
patches. 

(^.)  The  Choroid. — White  spots  occur,  either  new  forma- 
tions or  the  results  of  atrophy,  with  destruction  of  the  pig- 
ment normally  found  there. 

It  may  be  convenient  here  to  indicate  shortly  the  ophthal- 
moscopic appearances  in  one  or  two  diseases  in  which  reti- 
nal changes  are  most  frequent  and  important. 

Cerebral  Tumors. — In  most  cases  optic  neuritis  is  present. 
At  first  there  is  congestion,  increased  redness,  swelling, 
and  cloudiness  in  the  disc;  then  neuritis  sets  in,  with  ob- 
scuration of  the  edges,  followed  by  great  swelling  and 
strangulation  of  the  papilla  (choked  disc). 

Locomotor  Ataxia. — Atrophy  of  the  optic  nerves  is  a  fre- 
quent symptom  in  locomotor  ataxia,  and  it  is  also  some- 
times seen  in  general  paralysis,  and  occasionally  in  insular 
sclerosis.  The  disc  is  pale,  small  in  size,  and  excavated, 
and  the  retinal  vessels  are  usually  diminished  in  calibre. 

Bright' s  Disease. — Particularly  in  the  cirrhotic  form  of 
this  disease,  special  retinal  changes  (retinitis  albuminurica) 
take  place.  These  consist  in  {a)  oedematous  swelling  of 
the  retina;  [b)  white  degenerative  spots  and  patches;  (c) 
small  extravasations;  (d)  inflammation  of  the  papilla;  (<?) 
consecutive  atrophy  of  the  nerve  and  retina. 

Leucocythoemia. — In  this  disease  the  retina  is  pale,  the 
veins  dilated.  Small  extravasations  of  blood  are  frequent, 
and  sometimes  small  white,  lymphoid  deposits  are  seen 
scattered  over  the  retina. 

c 

HEARING. 

Such  affections  of  hearing  as  arise  from  pathological  con- 
ditions in  the  external  meatus,  the  Eustachian  tube,  and 
the  middle  ear,  belong  to  the  domain  of  surgery,  and  need 
not  here  be  discussed.  It  is  sufficient  to  point  out  that 
deafness  arising  from  affection  of  the  nervous  apparatus 
may  be  distinguished  from  that  caused  by  abnormalities  of 
the  conducting  apparatus  by  means  of  the  tuning-fork  test. 
When  a  vibrating  tuning-fork  is  placed  on  the  vertex,  the 
sound  is  heard  most  distinctly  in  the  deaf  ear  if  the  deaf- 
ness be  due  to  defective  conduction,  because  the  waves  of 


NERVOUS   SYSTEM.  245 

sound,  in  their  passage  from  the  cranial  bones  outward 
through  the  meatus,  are  obstructed  and  thrown  backward 
again  and  again  on  the  internal  ear.  If,  however,  the  de- 
fect of  hearing  arises  from  impairment  of  the  auditory 
nerve,  the  sound  of  the  fork  will  not  be  so  distinctly  heard 
on  the  deaf  side. 

Hyperaesthesia  of  the  auditory  nerves  is  common  in  hys- 
teria, acute  diseases,  and  insanity,  and  it  may  result  from 
paralysis  of  the  stapedius  muscle,  with  consequent  over- 
tension  of  the  membrana  tympani  in  cases  of  facial  paraly- 
sis. Auditory  hyperaesthesia  is  frequently  associated  with 
various  subjective  phenomena,  such  as  tinnitus  and  vertigo, 
the  latter  of  which  has  been  already  considered.  Anaes- 
thesia of  the  sense  of  hearing  may  result  from  blows  on  the 
head,  meningitis,  cerebral  and  cerebellar  disease,  scarla- 
tina, measles,  typhus  fever,  and  hysteria,  and  may  be 
brought  on  by  the  administration  of  quinine.  Deaf-mut- 
ism is  most  frequently  congenital,  the  result  of  defective 
development  of  the  internal  or  middle  ear.  When  it  is  ac- 
quired, it  is  usually  the  consequence  of  some  severe  disease 
in  childhood. 

TASTE. 

The  sense  of  taste  is  located  in  the  surface  of  the  tongue, 
fauces,  and  back  wall  of  the  pharynx.  The  root  of  the 
tongue  (circumvallate  papillae),  fauces,  and  pharynx  are 
supplied  by  the  glossopharyngeal  nerve.  The  taste  nerve 
for  the  anterior  two  thirds  of  the  tongue,  on  the  other 
hand,  is  the  lingual,  and  the  majority,  if  not  the  whole  of 
the  sensory  fibres  of  taste,  pass  from  the  lingual  into  the 
chorda  tympani  and  then  to  the  facial,  which  nerve,  how- 
ever, they  leave  below  the  geniculate  ganglion,  to  join  (by 
channels  at  present  unknown)  the  fifth  nerve,  in  the  trunk 
of  which  they  pass  to  the  brain. 

To  test  the  sense  of  taste  the  patient  should  be  made 
with  closed  eyes  to  protrude  his  tongue,  on  different  points 
of  which  the  substances  in  solution  used  in  testing  are  to 
be  deposited  by  means  of  a  glass  rod.  For  bitter  tastes,  so- 
lutions of  quinine,  picric  acid,  and  infusion  of  quassia  may 
be  employed;  for  sweet,  syrup  is  the  most  convenient;  acid 
taste  will  be  produced  by  the  application  of  vinegar  or  di- 
lute acids;  and  saline  by  means  of  solutions  of  common  salt, 
bromide^  or  iodide  of  potassium.    Sweet  tastes  are  best  felt 


246  MEDICAL  DIAGNOSIS. 

at  the  tip  of  the  tongue,  acid  at  the  edges,  and  bitter  at 
the  root  of  the  organ.  Perhaps,  however,  the  most  accu- 
rate method  of  testing  the  sense  of  taste  is  by  means  of  the 
constant  current.  Hyperaesthesia  of  the  sense  of  taste  is 
rarely  met  with,  but  it  occurs  occasionally  in  cases  of  hys- 
teria, Paraesthesiae  or  abnormal  sensations  of  taste  are 
sometimes  met  with  in  insanity. 

Ancesthesia  of  taste  may  be  peripheral,  due  to  a  coating  of 
fur  on  the  tongue,  or  abnormal  dryness  of  the  mouth,  or  to 
the  action  of  heat  or  cold.  It  may  also  be  due  to  defective 
conduction,  from  disease,  of  the  nerves  of  taste  in  their 
course.  In  this  way  it  may  arise  from  lesion  of  the  glosso- 
pharyngeal, when  the  defect  of  taste  will  be  limited  to  the 
root  of  the  tongue  and  fauces.  When  the  anaesthesia  in- 
volves the  anterior  two  thirds  of  the  tongue,  it  may  be  due 
to  disease  of  the  lingual  nerve,  of  the  chorda  tympani,  of 
the  facial  in  the  canal  of  fallopius,  or  of  the  fifth  nerve 
within  the  cranial  cavity. 

SMELL. 

The  sense  of  smell  is  conveyed  to  the  brain  solely  by  the 
olfactory  nerves.  The  branches  of  the  fifth  nerve  distrib- 
uted to  the  nasal  mucous  membrane  have  only  to  do  With 
common  and  tactile  sensation.  To  test  the  sense  the  pa- 
tient must  be  made  to  smell  various  odoriferous  substances, 
such  as  the  essential  oils,  musk,  camphor,  valerian,  etc.,* 
and  to  hold  in  the  mouth  such  articles  as  cheese,  wine,  and 
liqueurs,  which  owe  their  agreeable  flavor  to  the  sense  of 
smell  (the  latter  test  is  particularly  useful  when  the  nostrils 
have  become  occluded).  Hyperaesthesia  of  the  sense  of 
taste  is  occasionally  seen  in  hysteria  and  general  paralysis. 
Loss  of  smell  may  be  due  to  any  cause  which  prevents  the 
access  of  the  aromatic  particles  to  the  mucous  membrane, 
such  as  polypus,  catarrh,  abnormal  dryness  of  the  mem- 
brane (in  paralysis  of  the  fifth),  or  paralysis  of  the  muscles 
necessary  to  the  act  of  "  sniffing"  from  paralysis  of  the 
seventh  nerve.  But  apart  from  these  causes,  there  is  a  true 
anaesthesia  of  the  olfactory  nerve  (anosmia),  which  occurs 
in  hysteria,  tumor  of  the  brain,  embolism  of  the  middle 
cerebral  artery,  blows  on  the  head,  and,  as  Althaus  has 
pointed  out,  in  locomotor  ataxia. 

*  Such  substances  as  ammonia  and  acetic  acid  should  be  avoided,  as 
they  only  irritate  the  branches  of  the  fifth  nerve,  and  not  the  olfactory. 


NERVOUS   SYSTEM.  24^ 

CHAPTER  XXVIII. 

Nervous  System — (continued), 

MOTOR    FUNCTIONS. 

For  practical  purposes,  the  various  motor  functions  may 
be  arranged  in  the  following  manner : 

A.  Visce7'al  Motor  Functions. 

B.  Functions  of  Voluntary  Muscles. 

I. — ^Voluntary  Movements. 
(i.)  Paralysis. 
(2.)  Spasm. 

II. — Reflex  Actions. 

ii.)  Superficial  reflexes. 
2.)  Deep  reflexes. 

III. — Co-ordination. 

C.  Vaso-motor  Functions. 


A. — Visceral  Motor  Functions, 

The  movements  of  the  viscera  are  regulated  by  means  of 
so  complex  a  nervous  mechanism,  and  enter  as  yet  so  little 
within  the  scope  of  diagnosis,  that  they  need  only  be  very 
briefly  alluded  to  here.  There  are,  however,  certain  reflex 
actions  which  are  of  diagnostic  value  as  indicative  of  the 
condition  of  that  part  of  the  spinal  cord  where  their  centres 
are  situated. 

(i.)  Deglutition  has  already  been  spoken  of  under  the 
heading  of  the  "  Alimentary  System."  The  reflex  contrac- 
tions of  the  oesophagus  are  in  the  main  under  the  control  of 
a  centre  in  the  medulla,  and  cease  when  that  centre  is  dis- 
eased— as,  for  example,  in  advanced  bulbar-paralysis. 

(2.)  Micturition  a?id  Defcecation. — The  centres  for  these 
acts  lie  in  the  lumbar  enlargement  of  the  cord,  and  their 
performance  is  under  the  influence  of  the  will.  If  from  dis- 
ease of  the  cord  above  the  centres,  volition  is  cut  off,  then, 
when  the  faeces  have  sufficiently  accumulated,  or  the  urine 
collected  in  the  bladder  to  a  certain  amount,  these  excre- 
tions are  expelled  by  means  of  reflex  contraction.     Involve- 


248  MEDICAL  DIAGNOSIS. 

ment  of  the  sensory  tracts  in  the  disease  prevents  the  patient 
from  being  conscious  of  these  acts.  When  the  lumbar  cen- 
tres are  themselves  affected,  then  faeces  and  urine  are  evac- 
uated as  soon  as  they  enter  the  rectum  or  bladder. 

(3.)  Sexual  Fu7ictio7is. — These  functions  are  controlled  by 
a  reflex  centre  in  the  lumbar  enlargement  of  the  cord,  so 
close  to  that  for  the  cremasteric  reflex  that  the  condition 
of  that  reflex  affords  us  a  trustworthy  indication  of  that  of 
the  sexual  functions.  If  the  control  of  the  higher  centres 
is  cut  off  by  disease  in  the  upper  part  of  the  cord,  the  pro- 
cess becomes  imperfect,  and  may  sometimes  be  excessive 
(priapism).  Disease  of  the  sexual  centre  in  the  lumbar  en- 
largement causes  loss  of  sexual  power. 

(4.)  Respiration. — The  respiratory  centre  lies  in  the  me- 
dulla close  to  and  below  the  vaso-motor,  the  nceud  vital  of 
Fleurens.  In  advanced  bulbar-parlysis,  it  is  sometimes 
attacked  with  disease,  with  a  necessarily  fatal  result. 

B. — Motor  Functions  of  Voluntary  Muscles. 

I.  Voluntary  Movements  may  be  diminished,  or  they 
may  be  in  excess.  In  the  former  case  we  speak  of  paralysis 
(akinesis)  or  paresis,  according  as  the  loss  of  muscular 
power  is  abolished  or  only  diminished,  and  in  the  latter  of 
spasm  (hyperkinesis). 

(i.)  Paralysis  (akinesis)  of  the  voluntary  muscles  varies 
in  its  extent.  It  may  be  limited  to  one  or  two  muscles,  or 
it  may  affect  all  the  muscles  of  one  lateral  half  of  the  body 
(hemiplegia),  or  of  both  sides  of  the  body  symmetrically, 
usually  both  lower  limbs  (paraplegia). 

To  examine  the  state  of  the  muscular  system,  it  is  neces- 
sary to  cause  the  patient  to  go  through  all  varieties  of 
voluntary  movement,  simple  and  combined,  standing,  walk- 
ing, stepping  up  upon  a  chair,  etc.,  as  well  as  such  actions 
as  speaking,  writing,  and  the  like,  which  require  great  ac- 
curacy and  precision  in  the  movement  of  the  muscles 
brought  into  action.  The  dynamometer  may  be  employed 
for  ascertaining  the  force  of  the  muscular  contraction. 

Electric  Currents  are  of  the  utmost  use  in  diagnosis,  but 
the  limits  of  this  work  prevent  the  various  forms  of  appa- 
ratus being  described.  For  such  information  the  reader  is 
referred  to  special  works  on  the  subject.*     It  will  be  suf- 

■^  Such  as  Tibbit's  "  Medical  Electricity,"  or  Ziemssen's  "  Elektricitat 
in  der  Medicin." 


NERVOUS   SYSTEM.  249 

ficient   here  to  indicate  very  briefly  the  inferences  to  be 
drawn  from  the  information  so  obtained. 

The  Faradic  or  Indticed  Current  excites  muscular  contrac- 
tion when  the  stimulus  is  applied  to  the  motor  nerve  in  its 
course,  or  over  the  muscle  itself.  The  contraction  so  in- 
duced varies  from  a  scarcely  perceptible  change  up  to 
tetanus,  according  to  the  strength  of  current  used. 

The  Galvanic  or  Co7itinuous  Current  only  gives  rise  to  con- 
traction when  the  current  is  opened  or  closed,  not  when  it 
is  passing.     The  reaction  of  each  pole  must  be  separately 
investigated,  the  other  being  placed  upon  the  sternum. 
The  Law  of  Normal  Contractio?i  is  as  follows  : 
Weak  Currents — 
Positive  pole  (anode) — No  contraction. 
Negative  pole  (cathode) — Contraction  when  the  cur- 
rent is  closed,  expressed  by  the  formula  C.C.C.  (cath- 
odal closing  contraction) ;  none  when  it  is  opened. 
Currents  of  Medium  Stre?igth — 

Positive  pole — Slight  contraction  both  on  opening  and 
on  closing  the  current,  expressed  by  the  formulae 
A.O.c.  and  A.C.c,  anodal  opening  contraction  and 
anodal  closing  contraction,  the  small  c.  indicating 
that  the  contraction  is  slight. 
Negative  pole — Strong  contraction  on  closing  the  cur- 
rent, expressed  by  the  formula  C.C.C'.,  cathodal 
closing  contraction,  the  accent  on  the  last  C  indicat- 
ing that  the  contraction  is  strong. 
Strong  Currents — 

Positive  pole — Contraction  both  on  opening  and  on 
closing  the  current,  expressed  by  the  formulae  A.O.C, 
A.C.C. 
Negative  pole — Tetanus  when  the  current  is  closed, 
slight  contraction  when  it  is  opened,  expressed  by 
the  formulae  C.C.Te.,  cathodal  closing  tetanus,  and 
C.O.c,  cathodal  opening  slight  contraction. 
Various   forms  of  paralysis  may  be  accurately  classified, 
as  Erb  has  shown,  by  means   of  the  electrical  reactions   of 
the  muscles  and  nerves,  as  follows: 

a.  No  Change  in  the  Elect7'ic  Excitability  \Yith.  either  form  of 
current  (cerebral  paralysis,  myelitis,  rheumatic,  and  trau- 
matic peripheral  paralysis). 

b.  Quantitative  Change  in  the  Electric  Excitability — 

(^.)  Increase. — This    condition    is    uncommon,    but    is 
sometimes  found  in  the  first  stage  of  cerebral  hemi- 


250  MEDICAL  DIAGNOSIS. 

plegia,   in  certain  forms  of  locomotor  ataxia,  and 
rarely  and  transitorily  in  peripheral  paralysis  at  its 
commencement. 
{fi.)  Diminution  is  rare  in  cerebral  paralysis,  but  does 
sometimes  occur  in  the  later  stages  of  labio-glosso- 
pharyngeal  paralysis.     It  occurs  in  such  spinal  para- 
lyses as  are  accompanied  with  muscular  atrophy, 
c.   Quantitative  and  Qualitative  Changes  ("  Reaction  of  De- 
generation,"— Erb^ — The  reactions  of  nerve  and  muscle  are 
different,  and  must  be  separately  stated  as  follows: 
Nerves. 

Two  or  three  days  after  the  paralysis  has  begun,  the  ex- 
citability of  the  nerves  diminishes,  and  gradually  becomes 
completely  lost.  Should  recovery  take  place,  the  excitabil- 
ity reappears,  but  commonly  it  is  later  in  being  regained 
than  voluntary  motion. 
Muscles. 

To  the  Faradic  current  they  behave  much  as  the  nerves 
do — the  excitability  being  gradually  lost,  and  as  gradually 
regained  on  recovery  taking  place. 

The  galvanic  excitability  falls  parallel  with  the  Faradic 
for  about  a  week,  but  in  the  course  of  the  second  week  it 
begins  to  rise,  until  a  point  is  reached  when  the  muscles 
contract  with  stimuli  which  would  have  no  apparent  effect 
upon  them  in  their  normal  condition.  A  qualitative  change 
has  also  taken  place,  the  positive  closing  contraction  in- 
creasing until  it  equals  or  surpasses  in  intensity  the  nega- 
tive closing  contraction,  while  the  negative  opening  con- 
traction becomes  equal  to  or  exceeds  the  positive.  By 
glancing  at  the  normal  law  of  contraction  already  given, 
it  will  be  seen  that  in  this  form  of  paralysis  the  condi- 
tions are  exactly  reversed.  After  a  time  this  galvanic  ex- 
citability of  the  muscles  diminishes,  and  in  incurable  cases 
disappear ;  but  when  recovery  takes  place,  the  normal 
state  of  matters  becomes  gradually  restored.  This  ''reac- 
tion of  degeneration"  occurs  wherever  peripheral  nerves 
are  affected  in  their  course,  and  also  in  lead-poisoning,  in 
poliomyelitis  anterior  acuta,  and  in  progressive  muscular 
atrophy. 

(2.)  Spasm  (hyperkinesis)  of  the  voluntary  muscles,  may 
be  defined  as  abnormal  muscular  contraction,  the  result 
either  of  pathological  irritation  or  of  a  physiological  stimu- 
lus, to  which  the  resulting  contraction  is  disproportionate. 
It  is  of  two  varieties — tonic  and  clonic — the  former  indicat- 


NERVOUS   SYSTEM.  25  I 

ing  a  condition  of  muscular  contraction  which  remains  of 
nearly  equal  intensity  for  a  lengthened  period  (minutes, 
hours,  or  days),  while  under  the  latter  term  (clonic),  is  un- 
derstood a  condition  of  rapidly  alternating  muscular  con- 
traction and  relaxation,  whereby  particular  parts  of  the 
body  are  set  in  motion. 

Of  clonic  spasms  the  simplest  is  tremor^  which  varies 
from  the  slightest  fibrillary  twitching  of  the  lips  or  tongue 
to  the  most  well-marked  shaking  of  the  limbs  which  para- 
lysis agitans  exhibits.  Still  more  pronounced  is  the  clonic 
spasm,  which  occurs  in  convulsions  of  all  kinds  (epileptic, 
uraemic,  hysterical,  etc.),  in  which  the  whole  body  may  be 
violently  tossed  about  by  the  muscular  contractions. 

Tonic  spasm  is  most  commonly  seen  as  "cramp,"  contin- 
uous and  painful  contraction  of  muscles  individually  or  in 
groups;  also  in  catalepsy  and  in  contracture  (persistent 
shortening  of  muscle,  owing  frequently  to  changes  in  nu- 
trition), and  occasionally  in  the  muscles  used  in  certain  co- 
ordinated movements. 

In  connection  with  spasm,  it  is  to  be  noted  that  certain 
points  are  often  to  be  found,  pressure  upon  which  either 
excites  or  arrests  the  spasm  (motor  exciting  and  motor  ar- 
resting pressure  points).  This  is  particularly  noticeable  in 
connection  with  facial  spasm. 

II. — Reflex  Movements  of  Voluntary  Muscles. 

The  spinal  cord  has  throughout  its  whole  length  numer- 
ous centres  of  reflex  action.  The  stimulus  enters  the  cord 
through  the  posterior  nerve  root,  traverses  the  gray  matter, 
and  passes  out  again  through  the  anterior  roots,  giving  rise 
to  muscular  contractions.  Many  of  the  simpler  reflex  ac- 
tions can  readily  be  induced  by  the  physician,  and  they  are 
of  great  diagnostic  value  in  that  their  persistence  is  an  in- 
dication that  no  disease  of  importance  exists  in  the  reflex 
loop  in  question.  Gowers*  gives  a  very  full  description  of 
the  more  important  of  these,  and  it  is  to  be  observed  that, 
as  we  can  originate  reflex  actions  which  have  their  centres 
at  almost  every  point  in  the  length  of  the  cord,  we  can  thus 
gain  information  regarding  its  condition  throughout  its 
whole  extent.  These  reflexes  are  of  two  kinds — superficial 
and  deep. 


*  <i 


The  Diagnosis  of  Diseases  of  the  Spinal  Cord,"  London,  1880, 


252  MEDICAL  DIAGNOSIS. 

Superficial  Reflexes. 

(i.)  Plantar  Reflex. — Tickling  the  skin  of  the  Sole  gives 
rise  to  contraction  of  the  muscles  of  the  foot;  centre  in  the 
lower  part  of  the  lumbar  enlargement. 

(2.)  Gluteal  Reflex. — Tickling  the  skin  of  the  buttock  de- 
termines in  many  persons  a  contraction  of  the  gluteal 
muscles;  centre  probably  at  the  level  of  the  4th  or  5th  lum- 
bar nerves. 

(3.)  Creinasteric  Reflex. — Tickling  of  the  skin  on  the  inner 
aspect  of  the  thigh  is  followed  by  drawing  up  of  the  testi- 
cle; centre  at  the  level  of  the  ist  and  2d  lumbar  nerves. 

(4.)  Abdominal  Reflex. — On  stroking  the  skin  of  the  abdo- 
men from  the  costal  margins  toward  the  iliac  crests,  the 
abdominal  muscles  contract;  centres  lie  between  the  8th 
and  the  12th  dorsal  nerves. 

(5.)  Epigastric  Reflex. — Tickling  the  skin  of  the  chest  over 
the  4th,  5th,  and  6th  intercostal  spaces,  causes  a  dimpling 
of  the  epigastrium;  centres  from  the  level  of  the  4th  to  the 
6th  or  7th  dorsal  nerves.  The  same  region  of  the  cord  con- 
tains centres  for  the  reflex  contraction  of  the  erectores 
spinae,  which  occurs  when  the  skin  is  stroked  from  the 
angle  of  the  scapula  down  to  the  iliac  crest. 

(6.)  Scapular  Reflex. — Tickling  of  the  skin  in  the  intersca- 
pular region  gives  rise  to  contraction  of  the  scapular  mus- 
cles; centre  at  the  level  of  the  lower  two  or  three  cervical, 
and  the  upper  two  or  three  dorsal  nerves. 

Deep  Reflexes. 

The  afferent  impressions  which  excite  these  have  their 
origin  in  tendons  or  muscles — probably  the  latter.  The 
chief  of  these  are — 

(i.)  The  K7iee  Reflex. — If  the  knee  be  flexed,  and  the  leg 
be  allowed  to  hang  down  loosely,  a  tap  over  the  patellar 
tendon  will  give  rise  to  a  reflex  contraction  of  the  quadri- 
ceps femoris,  and  a  consequent  jerk  forward  of  the  leg. 
The  centre  for  this  reflex  lies  in  the  cord  at  the  level  of  the 
2d  and  3d  lumbar  nerves.  It  is  occasionally  absent  in 
health,  about  one  per  cent  of  individuals  not  exhibiting  it. 

(2.)  Ankle  Clonus. — In  certain  nervous  conditions,  a  sud- 
den pressure  upon  the  sole  of  the  foot  which  stretches  the 
muscles  of  the  calf,  gives  rise  to  a  series  of  spasmodic  con- 
tractions of  these  muscles,  which  recur  with  great  regular- 
ity, usually  about  5.7  times   per  second.     The  clonus  can 


NERVOUS  SYSTEM.  253 

also  sometimes  be  excited  by  a  tap  on  the  muscles  on  the 
front  of  the  leg.  Similar  reflexes  may  be  obtained  in  the 
arm. 

These  reflexes  are  impaired  by  disease  in  any  part  of  the 
reflex  loop — sensory  nerve,  posterior  nerve  roots,  gray  mat- 
ter of  the  cord,  anterior  nerve  roots,  or  motor  nerve.  The 
patellar  reflex  is  impaired  and  commonly  lost  in  locomotor 
ataxia.  It  is  excessive  in  disease  of  the  antero  lateral  col- 
umns, and  in  hemiplegia  on  the  diseased  side.  In  this  last- 
named  condition  the  superficial  reflexes  are,  on  the  con- 
trary, impaired  on  the  side  affected. 

III. — AFFECTIONS    OF    CO-ORDINATION. 

Such  complex  muscular  adjustments  as  are  involved  in 
standing,  walking,  etc.,  are  probably  co-ordinated  in  the 
cerebellum  and  higher  nervous  centre's.  They  may  be  in- 
terfered with  by  any  affection  of  the  brain,  spinal  cord,  or 
peripheral  apparatus. 

Labyrinthine  Vertigo, — In  Meniere's  disease  (disease  of  the 
semi-circular  canals)  inco-ordination  of  the  muscular  ad- 
justments of  the  body  may  be  observed  leading  to  vertigo 
or  to  peculiar  movements  in  particular  directions,  due  to  the 
fact  that  impressions  of  the  position  of  the  head,  derived 
from  the  terminal  nerve  apparatus  of  the  semi-circular 
canals,  have  failed  or  have  become  erroneous  owing  to  dis- 
ease of  these  canals. 

Ataxia  is  that  form  of  inco-ordination  which  accompanies 
disease  of  the  spinal  cord.  It  is  most  seen  in  the  actions  of 
standing  and  walking.  The  muscles  do  not  move  in  har- 
mony, the  movements  made  being  violent,  jerky,  and  ill- 
directed.  The  heel  is  brought  down  to  the  ground  sud- 
denly and  forcibly.  The  difficulty. of  movement  is  much 
increased  when  the  eyes  are  shut,  so  that  it  is  common  to 
make  such  a  patient  stand  with  his  heels  together  and  with 
his  eyes  closed,  in  order  to  test  his  power  of  co-ordination. 
The  ataxia  then  betrays  itself  in  swaying  and  tottering 
movements.  It  is  to  be  noted  that  the  ataxia  may  be,  and 
most  usually  is,  associated  with  normal  or  even  exaggerated 
muscular  power. 

Cerebellar  Inco-ordination. — Affections  of  the  cerebellum 
and  neighboring  ganglia  may  give  rise  to  various  symptoms 
of  inco-ordin'ation — reeling,  vertigo,  rigidity,  and  even 
sometimes  to  enforced    movements,    in    which    automatic 


254  MEDICAL  DIAGNOSIS. 

movements  of  the  voluntary  muscles  are  performed  in  spite 
of  the  will. 

Loss  of  muscular  co-ordination  in  connection  with  speech 
will  be  subsequently  considered. 

C. — Vasomotor  Functions. 

As  an  index  of  the  state  of  these  functions  we  have  to 
take  the  condition  of  the  skin  as  regards  pallor  or  redness, 
temperature,  and  the  amount  of  the  various  secretions. 
Such  changes  in  the  tissues  as  sloughing,  etc.,  are  rather 
to  be  referred  to  the  trophic  nerves. 

r. CUTANEOUS    VASOMOTOR    AFFECTIONS. 

Diffused  paleness  or  redness  of  the  skin  may  be  seen  in 
persons  in  perfect  health  (blushing,  etc.),  but  are  often  as- 
sociated with  nervous  disorders  such  as  epilepsy  and  hys- 
teria, and  may  be  induced  by  various  drugs,  as  for  ex- 
ample the  flushing  which  follows  the  inhalation  of  nitrite 
of  amyl. 

In  fever  the  vasomotor  nerves  of  the  skin  appear  to  be  in 
a  condition  of  abnormal  irritability.  The  hot,  cold,  and 
sweating  stages  of  ague  seem  to  depend  upon  general  tonic 
contraction  of  the  vessels  of  the  skin,  followed  by  general 
relaxation,  originating  in  all  probability  from  the  centre  in 
the  medulla.  More  local  changes  may  be  brought  on  by 
mechanical  or  chemical  irritation,  but  sometimes  occur  in- 
dependently of  such,  as  for  example  the  local  and  circum- 
scribed vasomotor  epileptic  aura,  which  Nothnagel  has 
described.  Further,  in  various  neuroses  (epilepsy,  Graves' 
disease,  etc.),  there  are  to  be  found  scattered  over  the  skin 
of  chest  and  abdomen  red  blotches  of  congestion,  to  which 
Trousseau  gave  the  name  of  tdches  ce?'ebrales,  and  which  may 
sometimes  be  excited  by  drawing  a  pencil  point  over  the 
skin.  Various  affections  of  the  central  nervous  system  are 
followed  by  vasomotor  changes  in  the  skin.  In  paraphlegia 
the  temperature  of  the  paralyzed  limbs  frequently  under- 
goes an  increase,  which  is  followed  by  a  diminution  when 
the  peripheral  nerves  are  affected.  In  cases  of  cerebral  hemi- 
plegia the  temperature  in  the  paralyzed  parts  is  almost  in- 
variably slightly  elevated,  and  remains  so  for  some  time. 
Ultimately,  however,  it  falls  again,  and  in  old  standing 
cases  not  only  is  the  temperature  on  the  affected  side  lower 


NERVOUS   SYSTEM.  255 

than  that  on  the  healthy,  but  the  pulse  is  smaller  and  more 
compressible,  and  the  hand  and  foot  pale  and  cold.  Unila- 
teral sweating  and  other  vasomotor  disturbances  are  not 
uncommon  in  Graves'  disease,  epilepsia,  and  hysteria. 

Visceral  Vasomotor  Affections. — Lesion  of  the  brain  and 
medulla,  and  even  passing  psychical  disturbances,  often  de- 
termine vasomotor  changes  in  internal  organs  (congestion 
of  viscera  in  hemiplegia,  disorders  of  menstruation  from 
emotions,  etc.).  The  secretions  are  often  affected  from  such 
causes.  The  urine,  in  particular,  is  liable  to  well-marked 
quantitative  and  qualitative  changes,  injury  of  the  4th  ven- 
tricle and  other  areas  in  medulla,  cerebellum,  and  cord, 
giving  rise  to  polyuria,  albuminuria,  and  glycosuria.  It 
seems  also  probable  that  certain  forms  of  enlargement  of 
the  liver  and  spleen  are  dependent  upon  vasomotor  changes 
determined  by  affections  of  the  central  nervous  system. 


CHAPTER  XXIX. 

Nervous  System. — {continued). 

TROPHIC    FUNCTIONS    OF    THE   NERVOUS   SYSTEM. 

Amidst  a  great  deal  that  is  uncertain  in  respect  to  these 
functions,  there  are  several  well-ascertained  facts  which  may 
be  briefly  alluded  to  here.  The  nutrition  of  all  the  tissues 
appears  to  be  under  the  control  of  the  nervous  system.  Even 
the  lower  portion  (cord,  nerves)  of  that  system  itself  are, 
as  the  descending  degenerations  show,  controlled  from  the 
higher  centres.  One  or  two  of  the  more  important  of  these 
trophic  changes  may  be  mentioned — 

il.  Muscular  Tropho-neuroses. — Muscles  may  atrophy  as  the 
result  of  local  causes,  or  as  a  consequence  of  long  inaction 
(such  as  follows  paralysis  from  cerebral  hemorrhage  or  em- 
bolism). Apart  from  these  causes,  when  active  neurotic  at- 
rophy of  the  muscles  occurs,  it  is  due  either  to  -disease  of  the 
nerve  cells  in  the  anterior  horns  of  gray  matter  in  the  spinal 
cord  or  corresponding  regions  in  the  medulla,  or  to  affec- 
tions of  those  nerve  fibres  which  connect  these  cells  with 
the  affected  muscles.  It  is  in  such  cases  that  electrical  ex- 
amination gives  the  "reaction  of  degeneratioa"  already  de^ 


256  MEDICAL  DIAGNOSIS. 

scribed,  and  hence  its  great  importance  as  a  means  of  diag- 
nosis. 

II.  Affections  of  Bones  and  Joints. — In  all  nervous  affec- 
tions, whether  peripheral  or  central,  changes  in  the  nutrition 
of  the  bones  and  joints  are  liable  to  occur.  Amongst  the 
best  known  are  those  whiclj  follow  locomotor  ataxia,  which 
may  be  acute  articular  swelling,  closely  resembling  rheu- 
matism, or  chronic  degenerative  changes,  leading  to  great 
deformities  and  strong  predisposition  to  fractures.  The 
important  point  to  note  in  regard  to  these  affections  is  that 
they  are  unaccompanied  with  pain. 

III.  Affections  of  the  skin. — So  far  as  is  yet  known,  the 
nerve  fibres  connected  with  cutaneous  nutrition  leave  the 
cord,  along  with  the  posterior  sensory  nerves,  and  it  ap- 
pears probable  that  they  spring  from  the  cells  of  the  pos- 
terior horns  of  the  cord.  Various  eruptions,  such  as  eryth- 
ema, urticaria,  eczema,  herpes,  may  arise  as  the  result  of 
disease  of  these  nervous  structures,  and  Paget  has  de- 
scribed an  affection  of  the  skin  of  the  fingers, ''  glossy  skin," 
which  is  due  to  the  same  cause.  Still  more  important,  as 
belonging  to  this  category,  are  the  acute  and  chronic  bed- 
sores, which  are  so  common  and  so  troublesome  in  spinal 
cases.  And,  finally,  there  have  to  be  noted  the  occurrence 
of  pigmentation,  and  of  affections  of  hair,  nails,  and  cuta- 
neous secretory  apparatus,  and  the  more  profound  lesions 
of  lepra  anaesthetica,  all  of  which  must  be  included  among 
the  cutaneous  tropho-neuroses. 

IV.  Affections  of  the  Secretory  Glands, — Salivation  and 
lacrymation,  as  well  as  the  flow  of  the  bile  and  other  secre- 
tions, are  under  the  influence  of  the  nervous  system,  but  do 
not  give  diagnostic  indications  further  than  has  been  al- 
ready noted  in  other  parts  of  this  work. 

V.  Affections  of  the  Viscera. — Of  these  too  little  is  known 
to  aid  in  diagnosis. 


CHAPTER  XXX. 

Nervous  System — [continued). 

CEREBRAL    AND    MENTAL    FUNCTIONS. 

In  many  diseases  of  the  nervous  system  the  intellectual 
powers  are  affected.     The  powers  of  attention  and  memory 


NERVOUS   SYSTEM.  257 

of  the  patient  are  put  to  sufficient  proof  while  the  physician 
is  informing  hiniself  regarding  his  history.  Decadence  of 
the  power  of  judgment  may  betray  itself  in  connection 
with  the  business  transactions  of  the  patient,  which,  if  ob- 
viously irrational,  will  usually  be  communicated  by  his 
friends.  The  most  obvious  interference  with  the  intellec- 
tual powers  is,  however,  loss  of  consciousness,  or  coma. 

Coma  is  met  with  in  simple  fainting,  in  injuries  of  the 
head,  in  apoplexy  (in  which  case  it  is  accompanied  with 
paralyses),  in  epilepsy  (usually  accompanied  with  convul- 
sions), in  hysterical  attacks,  in  catalepsy,  in  uraemia,  in  se- 
vere attacks  of  fever  of  various  kinds,  and  in  narcotic  poi- 
soning. It  is  sometimes  very  difficult  to  establish  a  diagno- 
sis between  alcoholic  poisoning,  for  example,  and  apoplexy, 
The  state  of  the  pupils,  the  smell  of  the  breath,  the  condi- 
tion of  the  heart,  and  the  presence  or  absence  of  paralysis, 
will,  however,  usually  make  clear  the  nature  of  the  case. 
Coma  vigil,  in  which  the  patient  lies  unconscious  with  the 
eyes  wide  open,  is  met  with  in  cerebral  diseases. 

There  are  certain  other  disorders  of  intelligence  which 
frequently  occur  in  mental  disease,  and  which  must  be  no- 
ticed here. 

Illusions  are  objective  disorders  of  perception — a  sound 
is  heard,  or  an  object  seen;  but  both  perceptions  are  misin- 
terpreted. 

Hallucinations,  on  the  other  hand,  are  subjective  disorders 
of  perception.  The  patient  may  imagine,  for  example,  that 
rats  are  running  over  the  bed-clothes,  or  that  he  hears  peo- 
ple calling  to  him,  when  no  foundation  exists  for  either  be- 
lief. These  are  hallucinations.  But  if  he  observe  some 
dark  object  on  the  bed  and  take  it  to  be  a  rat,  that  would 
be  an  instance  of  an  illusion. 

Delusions  have  no  relation  to  perception.  They  are 
purely  mental,  and  are  only  met  with  in  the  insane.  It  is 
not  uncommon,  for  example,  to  meet  with  such  delusions 
as  that  the  patient  believes  himself  to  be  the  Deity. 

Deliriu77i,  or  wandering  of  the  mind,  indicated  by  inco- 
herent speech,  may  consist  in  low  muttering  or  in  wild  and 
furious  shouting.  The  former  variety  is  most  frequently 
met  with  in  cases  of  nervous  exhaustion,  the  result  it  may 
be  of  fever,  or  of  any  grave  organic  disease.  The  more 
noisy  form  of  delirium  occurs  in  meningitis,  in  acute  mania, 
and  as  the  result  of  some  poisonous  ingredient  circulating 
in  the  blood,  such  as  alcohol,  fever  poison,  belladonna,  car- 


25S  MEDICAL   DIAGNOSIS. 

bonic  acid,  and  other  substances.  Delirium  may  also  be 
caused  by  reflex  irritation  in  connection  with  such  organs 
as  the  stomach  or  uterus.  A  variety  is  not  uncommon  in 
pneumonia,  and  is  even  occasionally  met  with  in  phthisis 
pulmonalis. 

It  is  also  important  to  note  further  the  condition  of  the 
patient  in  regard  to  mental  ejfiotions,  whether  these  are 
under  full  control  or  not.  This  is  very  obviously  not  the 
case  in  hysterical  persons,  and  in  many  other  nervous  affec- 
tions the  patient  may  be  observed  to  be  emotional  and  ex- 
citable. 

Speech. — The  physiology  and  pathology  of  speech  are  of 
a  most  complex  nature,  and  can  only  be  touched  upon  here. 
We  must  first  of  all  shut  out  all  imperfections  of  speech 
due  to  laryngeal  affections,  which  are  grouped  under  the 
head  of  aphonia,  and  which  are  apart  from  the  present 
subject. 

In  order  that  an  individual  may  employ  language  as  a 
means  of  communicating  with  his  fellows,  he  must  first  of 
all  be  able  to  understand  their  gestures  or  speech — the  re- 
ceptive and  regulative  department  of  speech  ;  and,  sec- 
ondly, he  must  be  able  to  express  his  own  mental  state  by 
means  of  gestures  or  speech — the  emissive  and  executive 
department. 

The  receptive  function  is  performed  by  means  of  the  vari- 
ous end  organs  of  special  sense,  and  by  the  nervous  appar- 
atus which  connects  these  with  the  central  organs.  Per- 
sons who  are  born  blind,  or  become  both  blind  and  deaf, 
are  examples  of  impairment  of  the  receptive  function  of 
speech. 

The  regulative  function  of  language,  or  that  whereby  the 
individual  reduces  to  order  and  to  comprehension  the  im- 
pressions which  reach  his  brain,  is  impaired  in  the  disease 
known  as  amnesic  aphasia.  This  affection  of  speech  takes 
many  different  forms.  Sometimes  the  patient  cannot  re- 
member the  names  of  things,  while  every  other  part  of  his 
sentences  comes  easily  to  him.  Sometimes  he  cannot  name 
an  object  held  up  in  front  of  him,  while  he  can  talk  and 
write  fluently.  At  other  times  the  initial  letter  of  the  word 
may  be  all  that  he  can  recollect.  Finally,  much  more  pro- 
nounced cases  are  often  met  with,  in  which  the  patient  can- 
not understand  spoken  or  written  language  at  all,  and  in 
which  his  own  words  are  meaningless.  Tlie  lesion  in  cases 
of  amnesic  aphasia  corresponds  to  the  distribution  of  the 


NERVOUS   SYSTEM.  259 

posterior  and  terminal  branches  of  the  middle  cerebral 
artery. 

The  emissive  function  of  language — viz.,  that  by  which 
the  speech  impulses  are  co-ordinated  before  being  sent  to 
the  executive  department,  is  impaired  or  lost  in  the  disease 
known  as  ataxic  aphasia.  The  patient  understands  per- 
fectly what  is  said  to  him  or  what  he  reads,  and  he  has  no 
difficulty  in  articulation,  but  he  is  unable  to  communicate 
his  thoughts  by  speech  or  by  writing  (agraphia).  His 
speech  consists  of  what  have  been  called  "recurring  utter- 
ances," which  may  or  may  not  chance  to  be  appropriate  to 
the  occasion,  and  which  do  not  possess  any  intellectual 
value.  The  lesion  is  usually  in  the  third  left  frontal  convo- 
*lution  or  in  the  island  of  Reil. 

The  executive  department  of  language,  that,  namely,  which 
regulates  articulation,  is  impaired  in  diseases  of  the  medulla 
oblongata  (bulbar  paralysis),  and  in  general  paralysis  of 
the  insane.  In  the  former  affection  the  speech  is  ''scan- 
ning," that  is,  the  words  are  uttered  syllable  by  syllable. 
In  the  latter  the  syllables  are  misplaced,  and  there  is  stut- 
tering and  stammering. 

For  details  regarding  the  pathology  of  the  function  of 
language  special  works  must  be  referred  to.  Enough  has 
been  given  here  to  show  how  any  particular  case  is  to  be 
classified. 

Sleep. — The  disorders  of  sleep  are  of  considerable  prac- 
tical importance.     They  are  mainly  three — 

1.  Somnolence. — Apart  from  the  natural  aptitude  for  sleep 
possessed  by  persons  of  a  lethargic  temperament,  the 
causes  of  somnolence  are  mainly  as  follows:  Exposure  to 
external  cold,  especially  when  combined  with  insufficient 
nu.triment ;  overloading  the  stomach  with  food;  dyspepsia; 
blood  poisoning  (uraemia,  fevers,  poisoning  with  narcotics, 
alcohol,  carbonic  acid,  etc.);  disease  of  the  brain. 

2.  Insomnia.,  or  want  of  sleep,  may  be  directly  due  to 
pain.  It  may  further  arise  from  excessive  mental  work, 
worry,  anxiety,  from  dyspepsia,  from  the  use  of  tea  or  cof- 
fee, from  cerebral  disease,  from  insanity,  and  from  heart 
disease. 

3.  Som?ia??tbulism. — In  this  case  also  a  definite  cause,  simi- 
lar to  the  above,  may  usually  be  found,  * 


26o  MEDICAL  DIAGNOSIS. 

CHAPTER    XXXI. 

Nervous    System — {continued'). 

CONDITION    OF    CRANIUM    AND    SPINE. 

Cranium. — The  condition  of  the  cranium  sometimes  af- 
fords important  indications  in  nervous  cases.  Thus  in  epi- 
lepsy we  may  find  a  distinct  localized  depression,  the  result 
of  an  old  depressed  fracture,  and  which  may  indicate  the 
cause  of  the  disease.  In  chronic  hydrocephalus,  again,  the 
peculiar  shape  of  the  skull  is  globular,  the  frontal  bones 
prominent,  and  the  eyeballs  protruding;  the  sutures  are 
open,  and  the  fontanelles  large  and  pulsating.  Occasion- 
ally, also,  tumors  of  the  cranial  bones  may  be  detected 
which  may  have  given  rise  to  symptoms  of  compression. 

Spine. — Examination  of  the  spine  includes  inspection, 
palpation,  percussion,  and  the  ''hot  sponge  test." 

Inspection. — The  patient  should,  if  practicable,  be  stripped, 
and  be  made  to  stand  upright,  with  the  feet  close  together 
and  firmly  planted.  If  an  ink  mark  be  made  on  the  skin 
over  the  tip  of  each  spinous  process,  the  line  of  the  spine 
will  be  rendered  distinct,  and  anv  lateral  curvature  will 
readily  be  detected.  At  the  same  time,  any  displacement 
of  the  column  caused  by  angular  curvature  will  become 
apparent. 

Palpation  of  the  spinal  column  should  be  practised  both 
posteriorly  and  anteriorly  through  the  abdominal  walls. 
Tumors  of  the  vertebrae  can  thus  be  dete(^ed. 

Percussio7i  of  the  spine  posteriorly  causes  pain  when  there 
is  disease  of  the  vertebrae,  or  of  the  spinal  membranes,  in 
myelitis,  in  spinal  irritation,  etc. 

Hot  Sponge  Test. — This  test  consists  in  passing  down  the 
spine  a  sponge  which  has  been  wrung  out  of  warm  water, 
and  which  is  not  so  hot  as  to  be  unpleasant  to  the  healthy 
skin.  In  certain  cases,  particularly  in  myelitis,  pain  is  ex- 
perienced by  the  patient  as  the  sponge  passes  over  the  seat 
of  the  disease. 


LOCOMOTORY   SYSTEM.  261 

CHAPTER  XXXII. 

LocoMOTORY   System. 

BONES — JOINTS — MUSCLES. 

Bones. — In  cases  of  suspected  syphilis,  the  surface  of  the 
bones,  particularly  the  cranium  and  tibia,  ought  to  be  care- 
fully examined  to  detect  the  presence  of  nodes.  The  soft- 
ness of  the  osseous  tissues  generally  in  cases  of  mollities 
ossium,  and  the  enlargement  of  the  articular  ends  of  the 
bones,  and  their  altered  shape  in  cases  of  rickets,  are  also 
to  be  looked  for. 

Joints. — An  examination  of  the  joints  must  be  made  when- 
ever pain  is  complained  of  in  them,  or  when  the  presence 
of  pyaemia,  rheumatism,  or  gout  is  suspected.  Allusion  has 
already  been  made  to  the  joint  affections  which  are  met 
with  in  locomotor  ataxia.  Hysterical  joint  affections  are 
more  surgical  than  medical  in  their  nature.  The  acute 
swelling  and  inflammation  of  the  joints  in  rheumatic  fever 
and  in  gout  is  usually  very  obvious.  In  rheumatoid  arthri- 
tis, also,  the  joints  become  enlarged,  deformed,  and  stiff, 
movement  being  accompanied  with  distinct  crackling. 

Muscles. — The  condition  of  the  muscular  system  has  al- 
ready been  to  a  large  extent  considered  under  the  head  of 
the  nervous  system.  The  following  points,  however,  de- 
mand further  notice: 

Rigidity  of  muscles  is  due  to  irritation  of  the  motor 
nerve  tissue.  This  sometimes  occurs  in  spastic  paralysis, 
in  meningitis,  and  sometimes  in  hysterical  paraplegia. 

Contracture^  or  persistent  shortening  of  muscles,  may  be 
due  to  paralysis  of  their  opponents  (secondary  contracture), 
to  cirrhosis  of  the  muscular  tissue  (myopathic  contracture), 
or  to  abnormal  innervation  (neuropathic  contracture). 

Flaccidity  occurs  when  the  muscle  has  become  atrophied. 

Fibrillary  twitchings  of  the  muscular  fasciculi  occur  in. 
many  spinal  affections,  but  are  most  marked  in  progressive 
muscular  atrophy. 

Muscular  paralysis,  spasm,  and  atrophy  have  been  already 
considered. 


APPENDIX  A. 


In  how  far,  from  an  examination  of  the  faeces,  the  physi- 
cian may  infer  what  is  the  exact  condition  of  the  intestinal 
tract,  is  a  question  of  some  difficulty.  The  following  points, 
which  may  be  of  use  in  localizing  catarrhal  affections  of  the 
intestines,  are,  in  great  measure,  derived  from  an  article  by 
Professor  Nothnagel  {Zeitsch?'ift  fiir  Klinische  Medicin,  vol. 
iv.  1882,  p.  223),  which  appeared  after  the  second  chapter 
of  this  work  was  in  type,  and  which  could  not,  therefore,  be 
interpolated  in  the  text. 

The  evacuation  of  pure  mucus  from  the  bowel  without 
any  admixture  of  faeces  points  to  catarrh  of  the  rectum. 
When  firm  faeces  are  passed,  completely  enveloped  in  mucus, 
we  may  conclude  that  the  morbid  process  affects  the  lower 
part  of  the  colon  and  the  rectum.  The  admixture  of  mucus 
with  the  faeces  in  abnormal  quantity  is  not  always  apparent 
to  the  naked  eye.  It  often  happens  that  when  the  faeculent 
matter  is  examined  microscopically  there  are  found  scat- 
tered intimately  through  it  small  masses  of  mucus,  which 
are  whitish-gray  hyaline  and  transparent.  This  peculiar 
admixture  of  mucus  indicates  that  the  catarrhal  affection  is 
limited  to  the  upper  portion  of  the  large  intestine  (and, 
possibly,  the  small  intestine),  while  the  rectum  and  de- 
scending colon  are  free  from  disease.  When  the  stools 
contain  small  masses  of  mucus  tinged  yellow  with  bile  pig- 
ment, we  may  conclude  that  the  small  intestine  has  become 
affected.  In  normal  faeces,  the  reaction  which  is  character- 
istic of  bile  pigment  cannot  be  obtained;  but  when,  from 
whatever  cause,  the  peristaltic  action  of  the  small  intestine 
is  increased,  this  characteristic  play  of  colors  will  be  seen 
on  the  addition  of  nitric  acid. 


APPENDIX  B. 


Method    of   Preparing    the   Solution   of  Nitrate   of 
Mercury  used  for  the  Determination  of  Urea. 

This  standard  solution  is  best  prepared  from  pure  mer^ 
cury.  Of  this  substance  71.48  grammes  are  to  be  carefully 
weighed  out,  placed  in  a  large  beaker-glass,  and  treated  with 
five  times  that  weight  of  pure  nitric  acid  of  specific  gravity 
1.425.  The  solution  so  obtained  is  to  be  warmed  in  a 
water  bath  until  all  the  nitrous  acid  vapor  has  been  driven 
off,  and  the  solution  has  become  colorless.  A  few  drops 
more  of  the  acid  are  to  be  added  until  nitrous  fumes  cease 
to  develop  themselves,  the  solution  evaporated  to  the  con- 
sistence of  syrup,  and  then  carefully  diluted  with  water  up 
to  one  litre.  The  accuracy  of  the  solution  of  nitrate  of 
mercury  so  obtained  must  now  be  tested  by  comparing  it 
with  a  standard  solution  of  urea,  prepared  in  the  following 
manner:  Two  grammes  of  pure  urea,  dried  in  vacuo  over 
sulphuric  acid,  are  dissolved  in  water  and  diluted  until  the 
fluid  has  a  volume  of  exactly  100  c.c.  Of  this  solution  10 
c.c.  contain  200  milligrammes  of  urea.  By  using  the  volu- 
metric method  detailed  in  the  text,  the  standard  solu- 
tion of  urea  being  substituted  for  the  urine,  the  exact 
strength  of  the  solution  of  nitrate  of  mercury  prepared  may 
be  readily  ascertained;  and  it  can,  if  necessary,  be  altered 
in  concentration  by  adding  more  mercury  or  more  water, 
as  the  case  may  be,  so  as  to  bring  it  to  the  exact  strength 
mentioned  in  the  text — viz.,  i  c.c,  corresponding  to  o.oi 
grammes  of  urea. 


INDEX. 


A. 

Abdomen,  auscultation  of,  60. 

examination  of,  42,  59,  60. 

form  of,  43. 

inspection  of,  43-45. 

movements  of,  45. 

palpation  of,  46-52, 

percussion  of,  53-60. 

prominence  of,  43. 

pulsation  in,  45. 

retraction  of,  44. 

tumors  in  45. 

walls  of,  41. 
Abdominal  aorta,  pulsation  of,  52. 

organs,  auscultation  of,  60. 

reflex,  252. 
Abdomino  -  vaginal    examination, 

263. 
Abducens,  nervus,  paralysis  of,  241. 
Abscess  of  throat,  32. 
Accentuation  of  heart  sounds,  86. 
Aceton,  216. 
Acetonaemia,  192-246. 
Achorion  Schonleinii,  182. 
Acidity  of  stomach,  31-37. 
Acid  fermentation  of  urine,  194. 
Acne,  178,  179,  180. 
Acuteness  of  vision,  239. 
Addison's  disease,  bronzing  in,  19. 
Adenia,  63. 
Adenitis,  simple,  62. 

syphilitic,  62. 

strumous,  62. 
Adherent  pericardium,  72,  73. 
Aegophony,  175. 
Aesthesiometer,  237. 
Agraphia,  259. 
Ague,  feeling  of  cold  and  heat  in, 

235. 
perspiration  in,  20. 
temperature  of,  24. 
vaso-motor  affections  in,  254. 


Air  cells,  epithelium  from,  in  sputa, 

125. 
Air    columns    in    lung    influencing 

percussion,  149-155. 
Akinesis,  248. 
Alar  thorax,  136. 
Albumen  in  sputa,  121. 

in  urine,  detection  of.  207. 
estimation  of,  208. 
varieties  of,  207 
Albuminuria,  210. 

transitory,  210. 
Alcoholic  poisoning,  257. 
Alimentary  system,  25-60. 
Alkaline    fermentation    of     urine, 

195. 
Alopecia  areata,  208 — footnote. 
Amaurosis,  239. 
Amblyopia,  239. 
Amenorrhoea,  227. 
Amnesic  aphasia,  258. 
Amphoric  resonance,  160. 

respiration,  168. 
Amyl- nitrite,    inhalation    of,    254- 
109. 

blushing  caused  by,  18. 
Anacrotic  pulse,  106. 
Anaemia,  blood  in,  65-68. 

blood  pressure  in  cases  of,  117, 

breathing  in,  138. 

color  of  urine  in,  190. 

leading   to    amenorrhoea,  227. 

menorrhagia  in,  227. 

oedema  in,  20. 

of  larynx,  132. 

pallor  of,  18. 

pallor  of  gums  in,  28. 
lips  in,  26. 

palpitation  in,  70. 

pulse  curve  of,  109. 

specific    gravity    of    urine   in^ 
194. 


266 


INDEX. 


Anaesthesia,  237. 

of  taste,  245. 

optic,  239-245. 
Analgesia,  237. 
Aneurism,  aortic,  70-75-101. 

aortic,    causing     paralysis    of 
recurrent    laryngeal    nerve, 

123- 

cough  of,  121. 

dulness  of,  28, 

of  abdominal  aorta,  52. 
Animal  parasites  of  skin,  185,  186. 
Ankle  clonus,  252. 
Anode,  249. 
Anorexia,  36. 

Antero-lateral  columns,  disease  of, 
knee  reflex  increased  in,  253. 
Anthrax,  66. 
Aorta,  abdominal,  aneurism  of,  52. 

thoracic,  dulness  of,  82. 
Aortic  aneurism,  causing  paralysis 
of  recurrent  laryngeal  nerve, 

134. 
area,  84. 

disease,  auscultation  of  arter- 
ies in,  98. 
diastolic  murmurs,  93. 
regurgitation,  sphygmographic 
tracing  of,  93. 

cardiographic    tracing  of, 

114. 
causing  capillary  pulse,  75. 
retinal   pulsation  in,  243. 
systolic  murmurs,  92. 
valves,  83. 
Apex-beat,  71. 

tracings  of,  112. 
Aphasia,  amnesic,  258. 

ataxic,  258. 
Aphonia,  causes  of,  129. 
Apices,  percussion  of,  160. 
Apoplexy,  257. 
Appetite,  depraved,  36. 
derangements  of,  36. 
excessive,  36, 
loss  of,  36, 
Argyle-Robertson   symptom,    243. 
Argyria,  20. 

Arteries,  atheromatous,  95. 
auscultation  of,  98. 
examination  of  the,  95. 
inspection  of,  95. 
murmurs  in,  99. 
palpation  of,  95. 


Arteries,  sounds  of,  99. 
Arterioles,    spasm  of,   causing  cy- 
anosis, 18. 
Arytenoid    muscle,    paralysis    of, 

134. 
Ascaris  lumbricoides,  42. 
Ascites,  43,  47,  53. 

distinguished     from     ovarian 

disease,  229. 
respiration  in,  138,  140. 
Asthma,  round  shoulders  in  cases 
of,  23. 
sputa  of,  127. 
Ataxia,  253. 
Ataxic  aphasia,  258. 
Atheroma,  95,  106,  108. 
Atrophy,  acute,  of  liver,  leucin  and 
tyrosin  in  urine  of,  224. 
of  optic  disc,  243. 
of  muscles,  255. 
Atropine,  dryness  of  mouth  after 

administration,  29. 
Attention,   257. 
Attitude,  23. 
Auditory    nerve,    anaesthesia    of, 

245- 

hyperaethesia  of,  245, 
Auscultation,  areas  for,  84. 

auscultation    respiratory    sys- 
tem, 163. 

of  abdominal  organs,  60. 

of  arteries,  98. 

of  heart,  83,  94. 

of  oesophagus,  35. 

of  veins,  loi. 

B. 

Bacilluria,  222. 

Bacillus  anthracis  in  blood,  65. 
Barrel-shaped  chest,  137. 
Basal  tone  of  percussion,  147. 
Bile  acids  in  urine,  218. 
Bile  pigment  in  urine,  218. 
Bilious  constitution,  22. 
Bilirubin,  relations  with  uro-bilin, 

190. 
Bi-manual  examination,  263, 
Bladder,  catarrh  of,  mucus  in  urine 
in,  212. 

gall,  49,  55. 

urinary,  59. 
Blebs,  180. 
Blindness,  239. 

color,  240. 


INDEX. 


267 


Blood,  estimation  of  haemoglobin 
in,  68. 
examination  of  the,  64-69. 
filaria,  in,  66. 
in  faeces,  41. 
in  sputuff^,  123. 
in  urine,  216. 
in  vomited  matter,  39. 
micro-organisms  in,  65. 
microscopic     examination     of 

the.  64. 
pigment  granules  in,  65. 
pressure,    estimation     of,    by 
sphygmomanometer,  117. 
Blood  corpuscles, — 
alterations  of,  65. 
enumeration  of,  66. 
in  urine,  218. 
Blue  line  on  gums,  28. 
Blushing,  254. 
Boiling  test  for  albumen  in  urine, 

207. 
Boils,   180. 

Bones,  condition  of,  261. 
nodes  on,  261. 
trophic  affections  of,  255. 
Bothriocephalus  latus,  42. 
Boulimia,  36. 
Bowels,  50,  60. 

cancer  of  causing  constipation, 
40. 
<Brain,  disease  of,  see  cerebral  dis- 
ease. 
Breathing,  see  respiration. 
Breasts,  229. 

Bright's  disease,    albuminuria  in, 
210. 
blood-pressure  in,  117. 
dry  skin  of  cirrohotic  form,  21. 
frequency   of    micturition    in, 

188. 
menorrhagia  in,  227. 
oedema  in,  20. 
ophthalmoscopic    appearances 

in,  244. 
pallor  of,  18. 

of  lips  in,  26. 
quantity  of  urine  in,  189. 
skin  affection  in,  181. 
specificgravity  of  urine  in,  193. 
tube  casts  in,  220. 
urea  diminished  in,  198. 
Bronchi,  obstruction  of,  vocal  fre- 
mitus in,  142. 


Bronchial  casts  in  sputa,  126. 

catarrh,  dry  riles  in,  173. 
harsh  breathing  in,  165. 
sputum  in,  122. 

respiratory  murmur,  166. 
Bronchiectasis,    sputum    of,     123, 

124,  126. 
Bronchitis,  cough  of,  97. 

sputum  of,  123,  124.  , 

Bronchocele,  63. 
Bronchophony,  174. 
Broncho-vesicular  respiration,  169. 
Bronzing  of  skin,  19* 
Bruit  de  diable,  loi. 

de  pot  fel6,  159. 

see,  also,  Murmurs. 
Bubbling  rales,  172. 
Bubo,  62. 
Bulbar  paralysis,  electricity  in,  249. 

laryngeal  paralysis  in,  133. 

palate  in,  33. 

salivation  in,  31. 

speech  in,  259. 

swallowing  affected  in,  35. 

tongue  in,  29. 
Bulging  of  thorax,    138,  144. 
Bullae,  180. 


O. 


Cadaveric  position  of  vocal  cords, 

133- 
Calculus   in   bladder,   pain   caused 
by,  188. 

renal,  pain  caused  by,  188. 

biliary,  see  Gall-stone. 
Callipers,  144. 

Cancer  of  bowels,   causing  consti- 
pation, 40. 

kidneys,  52. 

lymphatic  glands,  63. 

oesophagus,  35. 

omentum,  51. 

pallor  in  cases  of,  18. 

pancreas,  50. 

stomach,  36. 

tongue,  29. 
Capillaries,  defective  filling  of,  18. 

dilatation  of,  18. 

state  of,  100. 
Capillary  pulse,  75. 
Carbolic  urine,  191. 
Carbonate  of  lime  in  urine,  226. 
Carcinoma,  see  Cancer. 


268 


INDEX. 


Cardiac  auscultation,  83,  94. 

murmurs,  87. 

pain,  69. 

percussion,  80-82. 

pulsation,  71-76. 

region,  71. 

sounds,  86. 
Cardiograph,  iii. 

curve,  normal,  II2. 
Caries  of  teeth,  28. 
Carotid  pulsation,  73. 
Casts  of  bronchi,  126, 

rental  tubules,  220. 
Catalepsy,  251,  257. 
Cathode,  249. 
Cavernous  breathing,  168. 
Cavities,  air,  modifying  percussion, 

158. 
in  lung,  amphoric    resonance 
in,  160. 

bronchial  breathing  over, 

168. 
cracked-pot  sound  in,  159. 
metallic   tinkling  in,   172. 
vocal  resonance  over,  175. 
Cephalic  murmur,  100. 
Cerebellar  inco-ordination,  254. 
Cerebellum,   disease  of,  vertigo  a 

symptom  of,  236. 
Cerebral    affections,    paralysis    of 
tongue  in,  29. 
hyperaemia,  intolerance  of  light 

in,  239. 
and  mental  functions,  256. 
paralysis,    electric    conditions 

of,  249. 
tumors,   ophthalmoscopic    ap- 
pearances in,  244.    - 
Cervical  veins,  loi. 
Cervix  uteri,  dilatation  of,  265. 
Chancre,  soft,  62. 

hard,  62. 
Chest,  see  thorax. 
Chest-measurer,  145. 
Cheyne-Stokes  breathing,  139. 
Chlorides  in  urine,  estimation  of, 
202. 
quantity  excreted,  203. 
Chlorosis,  loi. 

cardiac  pain  in,  70. 
depraved  appetite  in,  36. 
gastric  pain  in,  36. 
leading  to  amenorrhcea,  227. 
pallor  of,  18. 


Chlorosis,  pallor  of  lips  in,  26. 
venous  murmur  in,  102. 

Cholera    collapse,    expression    In 
cases  of,  21. 
pinched  lips  of,  26. 

Cholesterin  in  urine,  224. 

Chorea,  movements  of  tongue  in, 
29. 

Choroid,  appearance  of,  244. 

Chylous  urine,  62-66. 

Cicatrices,  180. 

Cilio-spinal  region  of  cord,  243. 

Circulatory  system,  69-118. 

Cirrhosis    of    liver,    vomiting     of 
blood  in,  39. 

Clonic   spasm  of    voluntary    mus- 
cles, 250. 

Clonus,  ankle,  252. 

Coalminer's  nystagmus,  242. 

Cold    and   heat,  sensitiveness   to, 

235. 
Color  blindness,  240. 

of  urine,  190. 

perception  of,  240. 
Coma,  257. 

vigil,  257. 
Comedo,  179. 
Common  sensation,  236. 
Condensation  of  lung  tissue  caus- 
ing bronchial  breathing,  167. 
Conduction  of  sensory  impressions, 

rapidity  of,  237.  • 

Consciousness,  loss  of,  257. 
Consolidation  of  lung,  dry  rales  in, 

173. 

resonant  rales  in,  173. 

tympanitic  note  in,  158. 

vocal  resonance  in,  175. 
Constipation,  40. 
Constitutions,  22. 
Continued  fever,  24. 
Continuous  current,  action  on  mus- 
cles, 249. 
Contraction,  law  of  normal,  249. 

of  pupil,  242. 
Contracture  muscular,  251-261. 
Co-ordination,  affections  of,  253. 
Corpuscles,    blood,  alterations   of, 
in  form,  65. 

variations  in  number,  65. 

enumeration  of,  66. 
Cough,  120. 

its  frequency,  I2I. 

its  character,  121. 


INDEX. 


269 


Counter-irritants,    effects     of,    on 

skin,  211. 
Cracked-pot  sound,  159. 
Cramp,  251. 

Cranium,  condition  of,  260. 
Creatinin,  200. 
Cremasteric  reflex,  248-252. 
Crepitant  rale,  170. 
Cricothyroid  muscle,  paralysis  of, 

133. 
Crisis,  24. 
Croup,  132. 

breathing  in  cases  of,  138. 
Crusts,  180. 
Crystals  in  sputa,  127. 

asthma,  127. 
Curette,  266. 

Currents,   electric,  use  of  in  diag- 
nosis. 248. 

medium  effects  of,  249. 

strong  effects  of,  249. 

weak  effects  of,  249. 
Curvature,  spinal,  260. 
Cutaneous    vaso-motor   affections, 

254- 
Cutis  anserina,  179. 
Cyanosis,  18. 

of  lips,  26. 
Cyrtometer,  144. 
Cystin  in  urine,  205-224. 
Cystitis,  pain  of,  188. 

pus  in  urine  in,  219. 

D. 

Deafness,  244. 
Deep  reflex,  252. 
Defaecation,  40-247. 
Degeneration,  reaction  of,  250. 
Deglutition,  34-247. 

interference  with,  34. 
Delirium  257. 

tremens,  257. 

tremulousness  of  lips  in,  27, 
Delusions,  257. 
Demodex  folliculorum,  187. 
Dentition,  27. 
Desquamation,  180. 
Development,  17. 

Diabetes,    characters   of   urine   in, 
216. 

color  of  urine  in,  190. 

dry  skin  of,  20. 

dryness  of  tongue  in,  30. 

excessive  appetite  in,  36. 


Diabetes,  frequency  of   micturition 
in,  188. 
odor  of  urine  in,  192. 
quantity  of  urine  in,  189. 
saliva  in,  31. 
specific    gravity    of   urine    in, 

193- 

thirst  in,  36. 

urea  increased  in,  198. 
Diarrhoea,  40. 
Diastolic  aortic  murmur,  93. 

heart-sound,  83-84. 

mitral  murmurs,  91. 
Diathesis,  22. 
Dicrotic  notch,  105. 

pulse,  106-109. 
Dilatation  of  aorta,  dulness  in,  81. 
altering   second  sound  of 
heart,  86. 

of  cervix  uteri,  265. 

of  pupil,  242. 

of  right  auricle  increasing  car- 
diac dulness,  82. 
Diphtheria,  32. 

ocular  paralysis  after,  241. 

paralysis  of  larnyx  in,  133. 

paralysis  of  palate  in,  32. 

paralysis  of  pharynx  in,  34. 

throat  in,  33. 
Diplopia,  240. 
Disc,  see  optic  disc. 
Displacements  of  uterus,  265. 
Diuresis,  189. 

Dropsy,  see  ascites  and  oedema. 
Ducts,  thoracic,  61. 
Dynamometer,  248. 
Dysmenorrhoea,  228. 
Dyspepsia,  faintness  in,  36. 

pallor  of,  18. 

palpitation  in,  70. 

saliva  in,  31. 

tongue  in,  29. 

vertigo  a  symptom  of,  236. 
Dyspnoea,  140. 

attitude  in  cases  of,  23. 

breathing   through   mouth  in, 
27. 

heat,  138. 

E. 

Eating,  sensations  after,  36. 
Eclampsia,  spasm  of  tongue  in,  29. 
Eczema,  fissures  in,  181. 

marginatum,  185,  footnote. 


2/0 


INDEX. 


Eczema,  papulosum,  179. 

scales  of,  180. 
Electric  current,  use  of  in  diagno- 
sis, 249. 
Embolism,  cerebral,  tongue  in,  29. 
Emotions,  mental,  258. 
Emphysema,  putmonary,  breathing 
in,  139-141- 

diminishing    cardiac    dul- 

ness,  81. 
displacing  liver,  56. 

apex  beat,  76. 
enlargement  of  thorax  in, 

137. 
inspiratory     pressure     in, 

147. 
oedema  in,  19. 
percussion  note  in,  155. 
percussion     of    apices    of 

lung  in,  156,  161. 
round  shoulders  in,  23. 
subcutaneous,  20. 
Encephalic  murmurs,  100. 
Endocardial  murmurs,  87. 

thrills,  78. 
Enlargement  of  thorax,  137-144. 
Enumeration  of  blood  corpuscles, 

66. 
Epigastric  pulsation,  74. 

reflex,  252. 
Epiglottis,  paralysis  of,  133 
Epilepsy,  257. 

albuminuria,  after  an  attack  of, 

211. 
convulsions  of,  251. 
depressed     fracture,     causing, 

260. 
spasm  of  tongue  in,  29. 
vaso-motor  affections  in,  254. 
Epileptic  convulsions,  251. 
Epithelium  in  sputum,  125. 

in  urine,  220. 
Equilibrium  of  body,  238. 
Eructation,  37. 

Eruptions,    skin,    distribution   and 
configuration  of,  177. 
elements  of  skin    involved  in, 

178. 
etiology  of,  iSl. 
type  of,  178. 
Erythema  fugax, 

nodosum,  178. 
Eustachian  tubes,  orifices  of,  129. 
Excoriations,  180. 


Exocardial  murmurs,  94. 
Exophthalmic  goitre,  64-95. 

albuminuria  in,  112. 

palpitation  in,  153. 

prominence  of  eyeballs  in,  21. 
Expectoration,  see  sputa. 
Expiration,  prolongation  of,  in  ves- 

sicular  respiration,  165. 
Expiratory  pressure,  147. 

vesicular  murmur,  164. 
Expired  air,  measurement  of,  145. 
Expressfon  of  face,  21. 
Eyeball,  movements  of,  240. 
Eyelid,  drooping  of,  240. 
Eye,  muscles  of,  239. 


P. 


Face,  expression  of,  21. 

Facial   paralysis   affecting    palate, 

33. 
interfering    with    mastication, 

33- 
Faecal  tumors,  51. 
Faeces,  40. 

parasites  in,  42. 

blood  in,  41. 
Fainting,  70, 
Faintness,  36. 

Falsetto  voice  in  recurrent  paraly- 
sis, 133. 
Family  history,  16. 
Faradic  current,  action  on  muscles, 

249. 
Fasting,  sensations  during,  36. 
Fat,  17. 

in  urine,  256. 
Fauces,  examination  of,  32. 

ulceration  of,  32. 
Favus,  181. 

crusts,  180. 
Fehling's  test  for  sugar   in    urine, 

213. 
Female  reproductive  organs,  226. 
Fermentation  of  urine,  195. 

test  for  sugar  in  urine,  214. 
Ferro-cyanide  test  for  albumen  in 

urine,  208. 
Fever,  albuminuria  in,  210. 

attitude  of  patient  in  cases  of 
severe,  23. 

breathing  in,  138. 

color  of  urine  in,  190. 

delirium  of,  257. 


INDEX. 


271 


Fever,  deposits  of  urates  in  urine, 
223. 

diminution  of  urine  in.  189. 

excretion  of  chlorides  in,  203. 

excretion  of  phosphates  in,  206. 

hectic,  21. 

intermittent,  25. 

loss  of  appetite  in,  36. 

pulse-tracing  in,  ill. 

recurrent,  25-66. 

raiapsing,  25. 

remittent,  25. 

sordes  on  lips  in,  26. 

specific    gravity    of    urine    in, 
193 

temperature  in,  24. 

tongue  in,  29. 

urea  increased-in,  198. 

uric  acid,  excretion  in,  200. 

uro-bilin  in  urine  of,  190. 

vaso-motor  affections  in,  37. 
Fibrillary  twitching,  251. 
Fibrin  in  urine,  210. 
Field  of  vision,  239. 
Filaria  sanguinis  hominis,  66. 
First  sound  of  the  heart,  84. 
Fissures,  80. 

at  angle  of  lips  in  syphilis,  23- 
26. 
Flaccidity  of  muscles,  261. 
Flatulence,  38. 
Flea-bites,  187. 
Fluctuation  in  ascites,  48. 

in  thorax,  143. 
Fluor  albus,  228. 
Foreign  bodies  in  larnyx,  132. 
Form  of  thorax,  136. 
Formication,  235. 
Fourth  nerve,  paralysis  of,  241. 
Fremitus,  vocal,  142. 
Friction   distinguished  from  r§,les, 

174. 
Friction,  pericardial,  79-94. 

pleural,  143-173. 
Fundamental   tone    of   percussion, 

148. 
Fur  on  tongue,  30. 

G. 

Gall  bladder,  palpation  of,  50. 

percussion  of,  55. 
Gall-stones  in  faeces,  42. 

causing  vomiting,  38. 


Galvanic  current,  action   on   mus- 
cles, 248. 
Gastric  pain,  37. 

ulcer,  pain  of,  37. 
vomiting  of  blood  in,  39. 
General  paralysis  of  insane,  speech 
in,  259. 
tongue  in,  29. 
Giddiness,  235. 
Girdle  pain,  234. 
Gland,  thyroid,  63. 

thymus,  64. 
Glands,  trophic  affections  of,  256. 
lymphatic,  62. 

inflammation  of,  62. 
syphilis  of,  62. 
cancer  of,  63. 
ductless,  63. 
Globulin  in  urine,  208. 
Glottis,  oedema  of,  132. 

narrowing      of,       cracked-pot 
sound  in  cases  of,  159. 
Gluteal  reflex,  252. 
Glycosuria,  212. 
Goitre,  63-64. 

exophthalmic   albuminuria  in, 

210. 
prominence  of  eyeballs  in,  21. 
paralysis    of   recurrent   laryn- 
geal nerve  in,  134. 
Goose-skin,  179. 
Gout,  gastric  pains  in,  37. 

uric  acid  excretion  in,  200. 
Gouty  constitution,  22. 
Grape  sugar  in  urine,  213. 
Graphic  methods,  103. 
Grave's  disease,  vaso-motor  affec- 
tions in,  255. 
Grayness  of  skin,  20. 
Gums,  28, 


Habits,  16. 

Haemacytometer,  67. 

Haematemesis,  39. 

distinguished   from  haemopty- 
sis, 123. 

Haematin,  relations  with  uro-bilin, 
191. 

Haematuria,  217. 

Haemic  murmurs,  94. 

Haemoglobin  in  blood,  estimation 
of,  68. 

Haemoglobinuria,  217, 


2/2 


INDEX. 


Haemoptysis,    distinguished    from 

haematemesis,  123. 
Hair,  falling  out  of,  after  syphilis, 

23. 
Hallucinations,  257. 
Harsh  vesicular  respiration,  165. 
Headache,  causes  of,  235. 
Hearing,  affections  of,  244. 
Heart-burn,  37. 
Heart,  auscultation  of,  83-94. 
fatty,  pallor  in,  18. 
inspection,  71-75. 
murmurs,  87. 
normal  curve  of,  112. 
palpation,   76-79. 
percussion,  81-82. 
position  of,  79. 
sounds,  83-84. 

enfeeblement  of,  86. 
impurity  of,  86. 
intensification  of,  86. 
modifications  of,  85. 
reduplication  of,  87. 
valves  of,  83. 
Heart     disease,    albuminuria     in, 
210. 
ascites  in,  54. 
breathing  in,  138. 
cyanosis  in,  18. 
diminution  of  urine  in,  189. 
specific    gravity   of  urine   in, 

193- 

subcutaneous  oedema  in,  20. 

vertigo  a  symptom  of,  235. 
Heat  and  cold,  sensations  of,  235. 
Hectic  fever,  malar  flush  in,  21. 

temperature  in,  24. 
Height,  17. 

Hemi-albumose  in  urine,  209. 
Hemicrania,    redness    of   skin    in, 

19. 
Hemidrosis,  20. 
Hemiopia,  240. 
Hemiplegia,  248. 

knee  reflex  increased  in,  252. 

superficial  reflexes  diminished 
in,  253. 

tongue  in,  29. 

vaso-motor  affections  in,  255. 
Hepatic  dulness,  54. 
Herpes  zoster,  distribution  of,  178. 

pain  of,  119. 
Heteromorphism  of  thorax,  137. 
Hippocratic  succussion,  176, 


History,  16. 
Hodgkin's  disease,  63. 
Hot  sponge  test,  129. 
Husky   voice   in    laryngeal    affec- 
tions,  129. 
Hydatids  of  liver,  49. 
Hydrocephalus,  chronic,  shape  of 
skull  in,  260. 
squint  in,  21. 
Hydro-chinon,  191. 
Hydrogen,  sulphuretted,  in  urine, 

204,  • 

Hydrophobia,  salivation  in,  31. 
Hydro  bilirubin,  191. 
Hypersesthesia,   238. 
optic,  238-245. 
Hyperalgesia,  237. 

optic,  238. 
Hyperdicrotic  pulse,  no. 
Hyperidrosis,  20. 
Hyperpyrexia,  24. 
Hypertrophy,    of    left     ventricle, 
pulse  tracing  of,  no. 
blood  pressure  in,  117. 
causing    increase    of  dul- 
ness, 82. 
of  heart,  altering   position   of 
apex  beat,  76. 

increasing  strength  of  apex 
beat,  causing  increase  of 
dulness,  80. 
Hysteria,  257. 

breathing  in,  139. 
color  of  urine  in,  T90. 
convulsions  of,  251. 
cough  in  cases  of,  120. 
dyspnoea,  140. 
joint  affections  in,  261. 
spasm  of  tongue  in,  29. 
spasm  of  oesophagus  in,  35. 
vaso-motor  affections  in,  254. 


Ichthyosis,  179. 

Icterus,  see  jaundice. 

Illusions,  257. 

Incontinence  of  urine,  248. 

Indican  in  urine,  201. 

Induced  current,  action  on  muscles, 

249. 
Inferior  laryngeal  nerve,  paralysis 

of,  133- 
Inflammation   of   lungs,  see  pneu- 
monia. 


INDEX. 


273 


Inflammation  of  lymphatic  glands, 
62. 

of  lymphatic  vessels,  61. 

redness  of  skin  in,  19. 
Injuries,   previous,  23. 
Insomnia,  259. 
Inspection  of  abdomen,  43-45. 

arteries,  95. 

circulatory  organs,   71. 

liver,  45. 

nares,  128. 

respiratory  system,  135. 

stomach,  44. 

veins,  loi. 
Inspiratory  pressure,  147. 

vesicular  murmur,  164. 
Integumentary  system,  176-187. 

subjective  phenomena.  177. 

objective  phenomena,  177. 

eruptions,   177. 
Intellectual  powers,  256. 
Intensity    of     percussion     sound, 

149-153- 
Intercostal  neuralgia,  234. 
pain  of,  119. 

distinguished    from    pleurisy, 
119. 
Intermittent  fever,  25. 
Internal    thyro-arytenoid     muscle, 

paralysis  of,  134. 
Intestinal  obstruction,  indican  ex- 
cretion in,  202. 
Intolerance  of  light,  239. 
Iris,  see  pupil. 
Itching,  235. 

J. 

Jaundice,  19. 

yellow  sweat  in,  21. 

uro-bilin  in  urine  of,  190. 
Jerk,  knee,  252. 
Jerky  respiration,  165. 
Joints,   affections  of,    in    hysteria, 
261. 

in  rheumatism,  261. 

trophic  affections  of,  255. 
Judgment,  257. 


Kidneys,    disease    of,    causing   as- 
cites, 54. 
floating,  58. 
palpation  of,  51. 
percussion  of,  58. 


Kidneys,  tumors  of,  45-51. 
Knee  reflex,   252. 

li. 

Labia,  examination  of,  230. 
Labio-glossal  paralysis,  see  bulbar 

paralysis. 
Labyrinthine  vertigo,  253. 
Language,  259. 
Laryngitis,  cough  of,  121. 
Laryngoscopic  examination,  130. 
Larynx,  anaemia  of,  131. 

catarrh  of,  132. 

changes  in  color,  132. 

croup  of,  132. 

examination  of,  129. 

with  laryngoscope,  131. 

foreign  bodies  in,  132. 

movements  of,  132. 

nerves  of,  133. 

palpation  of,  129. 

paralysis  of  individual  muscles 
of,  134. 

stenosis  of,  breathing  in,  138. 

tumefaction  of,  132. 

ulceration  of,  132. 
Lead-  poisoning,    albuminuria    in, 
211. 

blue  line  on  gums  in,  28. 

paralysis  of,  250. 
Lenticular     ganglion,    disease  of, 

243- 
Leprosy,  179. 
Leucin  in  urine,  224. 
Leucorrhoea,  228. 
Leucocythaemia,  63. 
blood  in,  65. 
breathing  in,  138. 
ophthalmoscopic    appearances 

in,  244. 
spleen  enlarged  in,  49. 
uric  acid  excretion  in,  200. 
Lice,  180. 

Lichen  pilaris,   179. 
Light,  intolerance  of,  239. 
Lightening  pain.  235. 
Lips,  color  of,  26. 
form  of  the,  26. 
movements  of  the,  27. 
Liver,    acute    yellow    atrophy  of, 
leucin  and  tyrosin  in  urine, 

220. 
cirrhosis  of,  39-48. 
causing  ascites,  54. 


274 


INDEX. 


Liver,  diminution  of,  57. 

diseases  of,  causing  jaundice, 

19. 
diseases  of,  uric   acid  execra- 
tion in,  200. 
displacement  of,  56. 
enlargement  of,  56. 
examination  of,  45. 
hydatids  of,  49,. 
outline  of,  54. 
palpation  of,  48. 
percussion  of,  54. 

effect    of    respiration  on, 

55. 
size  of,  49. 
shape  of,  55. 
surface  of,  48. 
tenderness  of,  48. 
tumors  of,  45-49. 
tumors  of,  causing  bulging  of 

thorax,  137. 
waxy,  48. 
Locality,  sensation  of,  237. 
Locomotor    ataxia,    affections     of 
cutaneous      sensibility     in, 

237. 
affection  of  sense  of  smell  in, 

246. 
electric  conditions  of,  249. 
knee  reflex  lost  in,  253. 
ocular  paralysis  in,  241. 
ophthalmoscopic   appearances 

in,  244. 
tongue  in,  29. 
trophic  affections  of  joints  in, 

255- 
Locomotory  system,  261. 
Logwood,  urine  colored  by,  191. 
Louse,  187. 

Lung,    air   in,  influencing  percus- 
sion, 153-155. 
auscultation  of,  163. 
apices,  percussion  of,  160. 
cavities     in,    amphoric    reso- 
nance in,  160. 
amphoric  respiration  over, 

168. 
cracked-pot  sound  in,  159. 
percussion  of,  158. 
vocal  resonance  over,  175. 
cirrhosis  of,  shrinking  of  tho- 
rax in  cases  of,  138. 
collapse  of,  crepitant  rale  in, 
170. 


Lungs,  consolidation   of,    causing 
bronchial  respiration,  167. 
dry  rales  in,  173. 
resonant  rales  in,  173. 
tympanitic  note  in,  159. 
vocal  resonance  in,  175. 
regional    percussion   of,   161- 

162. 
relaxation    of,     cracked  -  pot 

sound  in,  159. 
rupture  of,  causing  sub-cutane- 
ous emphysema,  20. 
tissue  in  sputa,  126. 

relaxation  of,  causing  tym- 
panitic note,  157. 
tension  of,  influencing  per-, 
cussion,  155. 
tumor    of,     causing    enlarge- 
ment of  thorax,  137. 
vibration  of  air  in,  on  percus^. 
sion,  148. 
Lupus,  178-179. 
Lymphatic  constitution,  22. 

vessels,  inflammation  of,  6|, 
narrowing  of,  6i. 
dilatation  of,  61. 
rupture  of,  62. 
glands,  62. 

inflammation  of,  6J}. 
syphilis  of,  62, 
cancer  of,  63. 
Lymphangiectasis,  61, 
Lymphorrhagia,  61. 
Lysis,  25. 

ivn. 

Macules,  178. 

Malar  flush,  21. 

Malarious  fever,  blood  in,  65. 

Mammae,  228. 

Mania,  delirium  of,  257. 

Mastication,  33. 

Measles,  desquamation  of,  180. 

temperature  of,  25. 
Measurement  of  tracings,  note  on, 

117. 
Mediastinal  tumors,  loi. 
Medicines,  skin   eruptions   causc4 

by,  181. 
Melanaemia,  65. 
Melanin,  191. 
Memory,  257. 
Meniere's  disease,  236-253. 


INDEX. 


275 


Meningitis,  delirium  of,  257. 

excretion    of    phosphates    in, 

206. 
intolerance  of  light  in,  239. 
Menorrhagiia,  227. 
Menstruation,  227. 
Menstruation,  respiratory  system, 

143- 
Mental  emotions,  257. 
blushing  from,  18. 
pallor  from,  i8. 
Mental  functions,  257. 
Mercury  causing  looseness  of  teeth. 
28. 
salivation,  31. 
Mesenteric  glands,  tumors  of,  51. 
Metallic  tinkling,  172. 
Micro-organisms  in  blood,  65. 
in  sputa,  127. 
in  urine,  221. 
Microscopic  examination  of  blood. 
64. 

faeces,  42. 
sputa,  124. 
vomited  matter,  39. 
Microsporon  furfur,  185. 
Micturition,  247. 

frequency  of,  188. 
pain  after,  188. 
pain  before,  i8o. 
Migraine,  239. 
Milium,  179. 
Mitral  area,  84. 

diastolic  murmurs,  91. 
disease,  pallor  in  cases  of,  17. 

rapid  pulse  in,  96. 
incompetence,  86-90. 

cardiographic    tracing  in, 

115. 
causing  thrill.  78. 
sphygmographic      tracing 
in,  113. 
praesystolic  murmurs,  91. 
stenosis,  85,  87,  91. 

cardiographic    tracing  in, 

116. 
causing  thrill,  78. 
overfilling  of  jugular  veins 
in,  loi. 
systolic  murmurs,  90. 
valve,  83. 
Molities  ossium,  bones  in,  261. 
propepton  in  urine  of,  209. 
MoUuscum,  179. 


Moore's  test  for  sugar  in  urine,  214. 
Motor  functions  of  nervous  system, 
247. 
of  viscera,  247. 
of  voluntary  muscles,  248. 
Movements  of  eyeball,  240. 
larynx,  132. 
vocal  cords,  132. 
Mucous  cloud  in  urine,  192. 
Mucus  in  urine,  212. 
Muguet,  28-32. 
Murmurs,  aortic,  93. 
arterial,  99, 
cephalic,  100. 
endocardial,  87. 

character  of,  90. 

point  of  maximum  inteti- 

sity  of,  89. 
propagation  of,  89. 
rhythm  of,  89. 
exocardial,  94. 
haemic,  94. 
mitral,  90. 
origin  of,  87. 
pulmonary,  93, 
tricuspid,  92. 
Muscles,  contraction  of,  law  of  nor- 
mal, 249. 
contracture  of,  261. 
fiaccidity  of,  261. 
functions  of,  248. 
ocular  paralysis  of,  241. 

spasm  of,  241. 
paralysis  of,  245. 
reflex  movements  of,  251. 
rigidity  of,  261. 
spasm  of,  250. 
tropho-neuroses  of,  255. 
twitching  of,  251-260. 
Muscular  atrophy,  progressive, 250. 

tongue  in,  29. 
Muscular  sense,  238. 
Myelitis,  electric  conditions  of,  249. 
Myosis,  242. 

N. 

Naevi,  179, 

Narcotic  poisoning,  257. 

Nares,  examination  of,  128. 

inspection  of,  129. 

palpation  of,  128, 
Nasal  speculum,  128, 
Nausea,  38. 


2*]^ 


INDEX. 


Nerve,  abducens,  paralysis  of,  241. 
inferior  laryngeal,  paralysis  of, 

133- 
oculo-motor  (3d),  paralysis  of, 

240. 
optic,  243. 
recurrent   laryngeal,   paralysis 

of,  133. 
superior  laryngeal,  paralysis  of, 

133. 

trochlear  or  4th,  paralysis  of, 
241. 
Nerves,  ocular,  paralysis  of,  240. 

spasm  of,  241. 
Nervous  constitution,  22. 
Nervous  disease,  excretion  of  phos- 
phates in,  206. 
Nervous  system,  241-261. 

cerebral  and  mental  functions, 
256. 

condition  of  cranium  and  spine, 
260. 

motor  functions,  247. 

sensory  functions,  233. 

trophic  functions,  255. 

vaso-motor  functions,  254. 

Noeud  vital,  248. 

Neuralgia,  234. 

intercostal,  119-234. 

of  chest  wall  simulating  cardiac 
pain,  69, 

salivation  in,  31. 

visceral,  234, 
Neuritis,  optic,  243. 
Nitrate  of  silver  causing  argyria,  20 
Nitric  acid    test    for   albumen   in 

urine,  207. 
Nitrite  of  amyl,  inhalation  of,  254. 
Nodes  on  bones,  23,  261. 
Normal,  contraction,  law  of,  249. 

temperature,  24. 
Nostrils,  see  nares.-. 
Notch,  dicrotic,  105. 
Numbness,  235. 

Numeration  of  blood  corpuscles,66. 
Nummular  sputa,  124. 
Nystagmus,  242. 

O. 

Obstruction,  intestinal,  indican  ex- 
cretion in,  202. 
Ocular  muscles,  paralysis  of,  241. 
Oculo-motor  nerve,  240. 
Odor  of  urine,  192. 


CEdema,  causes  of,  20. 
glottidis,  132. 
of  lungs,    percussion   in,   154, 

155- 

sputum  of,  158. 
CEsophagus,  auscultation  of,  35. 
examination  of,  34. 
obstruction  of,  35. 

causing  retraction  of  abdo- 
men, 44. 
pain  in,  35. 
Omentum,  tumors  of,  45-51. 
Ophthalmoscopic  examination, 243. 
Optic  anaesthesia,  239. 
disc,  changes  in,  243. 
hyperaesthesia,  238. 
hyperalgesia,  238. 
nerve,  condition  of,  243. 
neuritis.  243. 
Organisms  in  blood,  65. 
Os  uteri,  examination  of,  232,  233. 
Osteomalacia,  excretion  of   phos- 
phates in,  206. 
Ovarian  disease. leading  to  amenor- 
rhoea,  227. 
tumors,  diagnosis  of,  229. 
Ovaries,  tumors  of,  45-52. 
Oxalate  of  lime  in  urine,  223. 
Oxaluria,  symptoms  of,  224. 
Oxyuris  vermicularis,  42. 

P. 

Pain,  234. 

cardiac,  70. 

caused  by  stricture  of  urethra, 
.  188. 

by  vesical  calculus,  188. 
girdle,  234. 
in  connection  with  respiratory 

system,  119. 
in  connection  with  urinary  sys- 
tem, 188. 
in  loins,  188. 
lightning,  235. 
in  supra- pubic  region,  188. 
of  cystitis,  188. 
of  inter-costal  neuralgia,  119. 
of  pleurisy,  119. 
of  pleurodynia,  II9. 
urethral,  188. 
Palate,  cicatrices  in,  after  syphilis, 

23. 
form  of,  33. 
paralysis  of,  33, 


INDEX. 


277 


Pallor,  causes  of,  18. 
Palpation  of  abdomen,  46-52. 

abdominal  aorta,  52. 

arteries,  95. 

circulatory  organs,  76. 

gall-bladder,  49. 

intestines,  50. 

addneys,  52. 

llarynx,  129. 

liver,  48. 

mesenteric  glands,  51. 

nares,  128. 

ovarian  tumors,  52. 

pancreas,  50. 

respiratory  system,  141. 

stomach,  50. 
Palpitation,  70. 
Pancreas,  palpation  of,  50. 

tumor  of,  50. 
Papules,  179. 
Paraesthesiae,  235, 
Para-globulin  in  urine,  208. 
Paralysis  agitans,  shaking  of  limbs, 
in,  251. 

general,  see  general  paralysis. 

of  crico-thyroid  muscle,  133. 

of  inferior  laryngeal  nerve,  133. 

of  muscles  of  epiglottis,  133. 

of  ocular  nerves,  240. 

of  superior  laryngeal  nerve,  133, 

of  tongue,  29. 

of  vocal  cords,  129-132. 

of  voluntary  muscles,  248. 

varieties    of,   distinguished  by 
electro-diagnosis,  249. 
Paraplegia,  248. 

vaso-motor  affections  in,  255. 
Parasites,  animal,  of  skin,  185. 

vegetable,  of  skin,  182. 
Parasitic  affections  of  skin,  182. 

worms  in  faeces,  42. 

causing    excessive    appe- 
tite, 36. 
Pareunia,  228. 
Patellar  reflex,  252. 
Pectoriloquie  aphonique,  175. 
Pectoriloquy,  footnote,  174. 
Pediculus,  187. 

Pepton  in  urine,  clinical  significance 
of,  211. 

detection  of,  211. 
Percussion,    feeling    of    resistance 
during,  160. 

in  ascites,  53. 


Percussion,  methods  of,  152. 

of  abdomen,  53-60. 

of  heart,  79-82. 

of  kidneys,  58. 

of  liver,  54. 

of  lungs,  152. 

of  spine,  260. 

of  spleen,  57. 

of  stomach,  59. 

regional,  162. 

theory  of,  147. 

topographical,  161. 
theory  of,  155. 

tympanitic,  156. 
Percussion  sound,  intensity  of,  149, 

153. 
pitch  of,  150-155. 
quality  of,  151. 
Pericardial  effusion   causing  bulg- 
ing, 137. 

increase  of  cardiac  dulness, 
80. 
friction,  82-94. 
Pericardium,  adherent,  72-73. 
Perimeter,  239. 

Perinaeum,  examination  of,  232. 
Peripheral  paralysis,  electric  condi- 
tions of,  249-250. 
Peristaltic  movements,  46. 
Peritoneal  cavity,  47. 

friction,  48. 
Peritonitis,  acute,  breathing  in,  138, 
140. 
drawing  up   of  upper   lip 

in,  21. 
knees  drawn  up  in,  23. 
pain  in,  47. 
chronic,  tenderness  in,  47. 
pelvic,  leading  to  amenorrhoea, 
227. 
Perspiration,  20. 
Per  vaginam  examination,  232. 
Perverted  sensations,  235. 
Petechiae,  181. 

Phosphate  of  ammonium  and  mag- 
nesium in  urine,  224. 
of  lime,  amorphous,  in  urine, 
224, 

crystallized,  224. 
of  magnesium  in  urine,  225. 
Phosphates  in  urine,  204. 

quantity  of,  206. 
Phthiriasis,  180. 
Phthisis,  amenorrhaea  in,  227. 


2/8 


INDEX. 


Phthisis,  TdIoocI  in,  65. 

blood  pressure  in  cases  of,  117. 

bronchial  breathing  in,  168. 

breathing  in,  141. 

causingshrinkingof  thorax,  137. 

cough  of,  120. 

expiratory  pressure  in,  147. 

form  of  thorax  in,  136. 

harsh  breathing  in,  165. 
[   heredity  of,  16. 

jerky  respiration  in,  165. 

moist  rales  in,  171. 

pallor  in  cases  of,  18. 

paralysis  of  recurrent  laryngeal 
nerve  in,  133. 

percussion  in,  155,  158. 

shrinking  of  apices  of  lung  in, 
162. 

sputum  of,  123,  124,  126,  127. 

subclavian  murmur  in,  98. 

sweating  in,  20. 

temperature,  24. 

tuberculebacillus  in  sputa  of, 
127, 

vocal  fremitus  in,  142. 

resonance  in,  175. 
Phymata,  179. 
Pica,   36. 

Pigeon-breast,  137, 
Pigmentation  of  skin,  18,  19. 
Pigments  of  urine,  190. 
Pitch  of  percussion  sound,  150-155. 
Pitting  of  small-pox,  23. 
Pityriasis  versicolor,  180. 
Plantar  reflex,  252, 
Plethora,  complexion  in,  18. 
Pleurae,  thickening  of,  percussion  in 

cases  of,  154. 
Pleural    effusions,     aegophony    in, 

175. 
breathing  in,  138-141. 
causing  enlargement  of  thorax, 

137- 
displacing  apex  beat,  76. 

liver,  56. 
modifying  percussion  note,  153, 

158. 
modifying  vocal  resonance,  175. 
shrinking  of  thorax   after  ab- 
sorption of,  138. 
vocal  fremitus  in,  142. 
Pleural  friction,  143. 
Pleurisy,  breathing  in,  138. 
cough  of,  120. 


Pleurisy,  friction  sound,  173. 

pain  of,  119. 

urea  increased  in,  199. 
Pleuritic  effusion,  bronchial  breath- 
ing above  the  level  of  a,  167. 

friction,  173. 
Pleurodynia     distinguished      from 

pleurisy,  119. 
Pleximeter,  vibrations  of,  148. 
Pneumatometer,  146. 
Pneumonia,  bronchial  breathing  in, 
167. 

causing  enlargement  of  thorax,' 
138. 

cough  of,  120. 

crepitant  rale  in,  170. 

excretion  of  chlorides  in,  203. 

malar,  flush  of,  21. 

percussion  in,  154,  155,  158. 

sputum  of,  123,  124,  127. 

temperature  of,  24. 

urea  increased  in,  198. 

vocal  fremitus  in,  142. 
resonance  in,  175. 
Pneumopericardium  abolishing  car- 
diac dulness,  81. 
Pneumothorax,    amphoric    reson- 
ance in,  160. 

amphoric  respiration  in,  169. 

cracked-pot  sound  in,  159, 

diminishing    cardiac    dulness, 
81. 

displacing  apex  beat,  76. 
liver,  56, 

metallic  tinkling  in,  172. 

percussion  note  of,  158. 
Poisoning,  gastric  pain  after,  38. 
Polarimeter,  216. 
Poliomyelitis,  anterior  acuta,  250. 
Pomphi,  179, 
Posterior  crico-arytenoid   muscle, 

paralysis  of,  134. 
Praecordia,  71, 

bulging  of,  71. 

depression  of,  71. 
Praesystolic  mitral  murmurs,  91. 

tricuspid  murmurs,  92. 
Pregnancy,  albuminuria  in,  211. 

bronzing  of  skin  in,  19. 

in  its  bearing  on  uterine  dis- 
ease, 227. 
Pressure  of  air  in  respiration,  147. 

points,  motor,  251. 

sensation  of,  236. 


INDEX. 


279 


Progressive     muscular      atrophy, 
250. 
tongue  in,  29. 
Propepton  in  urine,  209. 
Prostate,  hypertrophy  of,  frequen- 
cy of  micturition  in,  188. 
Prostatitis,  pain  of,  188. 
Prurigo,  180. 
Pruritus,  180-235. 
Psoriasis,  distribution  of,  178. 
fissures  in,  180. 
scales  of,  180. 
Pterygoid  thorax,  137. 
Ptosis,  240. 

Pudenda,  external,  230. 
Pulex  irritans,  187. 
Pulmonary  area,  84. 

cavities,  amphoric  respiration 
over,  168. 

bronchial  breathing  over, 

168. 
metallic  tinkling  in,  172. 
sputum  from,  123,  124. 
vocal  resonance  over,  175. 
consolidation,    dry    rales    in, 

173- 

tympanitic  note  in,  159. 

vocal  resonance  in,  175. 
disease,  cyanosis  in,  18. 

lips  in,  26. 
emphysema,  loi. 
murmurs,  93. 
oedema,    percussion    in,     154, 

155,  158. 

sputum  in,  122. 

valves,  83. 
Pulsation  at  root  of  neck,  73. 

arterial,  on  thoracic  wall,  75. 

capillary,  75. 

carotid,  72. 

epigastric,  74. 

in  abdomen,  45. 

jugular,  73. 

of  abdominal  aorta,  52. 

of  cardiac  apex,  72-76. 
Pulse,  radical,  95. 

anacrotic,  106. 

character  of,  97. 

dicrotic,  106-109, 

expansion  of,  97. 

frequency  of,  96. 

hyperdicrotic,  iio. 

rhythm  of,  96. 

tension  of,  97. 


Pulse,  volume  of,  98. 
Pulsus  alternans,  97. 

bigeminus,  97. 

celer,  97. 

intermittens,  97. 

paradoxus,  96. 

tardus,  97. 
Pupil,  Argyle-Robertson  symptom, 

243- 

changes  in  the,  242. 

contraction  of,  242. 

dilatation  of,  243. 

hippus,  243. 
Purpura,  179. 

menorrhagia  in,  227. 
Purpurin,  191. 
Pus  in  urine,  220. 
Pustules,  180. 
Pyelitis,  pain  of,  188. 

pus  in  urine  in,  220. 
Pylorus,  incompetence  of,  45. 
Pyrexia,  altering  heart  sounds,  85. 

diminishing  force  of  heart,  77. 

dry  skin  of,  20. 

Q. 

Quality  of  percussion  sound,  15 1. 
Quantitative  change  of  electric  ex- 
citability, 249. 

R. 

Radial  pulse,  95. 

character  of,  97. 

expansion  of,  97. 

frequency  of,  96. 

rhythm  of,  96. 

tension  of,  97. 

tracings  of,  105. 

volume  of,  97. 

{See  also  Pulse.) 
Rales,  bubbling,  172. 

crepitant,  170. 

distinguished     from    friction, 
174. 

dry,   173. 

moist,  171. 

resonant,  172. 

sibilant,  173. 

sonorous,  173. 
Rapidity  of   conduction   of  sensa- 
tions,  237. 
Reaction  of  degeneration,  250. 

of  urine,  194. 


28o 


INDEX. 


Recto-vaginal  examination,  232. 
Recurrent  fever,  25. 

paralysis,  133. 
Redness  of  skin,  18. 
Reduplication  of  heart-sounds,  86. 
Reflex,  abdominal,  252. 
cremasteric,  248-252. 
epigastric,  252. 
gluteal,  252. 
knee,  252. 
plantar,  252. 
scapular,  252. 
Reflexes,  deep,  252. 
superficial,  252. 
Regional  percussion,  162. 
Regions  of  thorax,  135. 
Relapsing  fever,  25. 
Relaxation  of  lung  tissue  causing 
tympanitic  note,  157. 
cracked-pot  sound  in,  159. 
Remittent  fever,  24. 
Renal   calculus,    pain    caused  by, 
189. 
dulness,  59. 
tube-casts,  220. 
Reproductive  system,  226. 
Resistance  during  percussion,  160. 
.Resonance,  amphoric,  160. 
explanation  of,  150. 
vocal,  174. 
Respiration,  amphoric,  168. 
bronchial,  166. 
broncho-vesicular,  169. 
Cheyne-stokes.  139. 
extent  of  movements,  141. 
frequency  of,  138. 
nervous  mechanism,  248. 
rhythm  of,  139. 
type  of,  140. 
vesicular,  164. 
Respiratory  centre,  disease  of,  139. 
movements  of  thorax,  138. 
rales,  170. 
system,  119. 

auscultation,  163. 
examination  of  nares  and 

larynx,  128.' 
inspection,  135. 
laryngoscopic      examina- 
tion, 130. 
mensuration,  143. 
pain   in  connection  with, 

119. 
palpation,   141. 


Respiratory  centre,  percussion, 
theory  of,  147. 
subjective        phenomena, 
119. 
Retina,  appearance  of,  244. 
Retinal  vessels,  243. 
Retro-pharyngeal  abscess,  33. 
Rhagades,  180. 
Rheumatic  constitution,  22. 

paralysis,    electric    conditions 
of,  249. 
Rheumatism,  acute,  acid  urine  in, 

195. 

joint  affections  in,  261. 

sweating  in,  20. 

urea  increased  in,  199. 

uric  acid  excretion  in,  200. 
Rhonchus,  171,  footnote. 
Rhubarb,  urine  colored  by,  IQI. 
Rhinoscopy,  129. 
Rickets,  bones  in,  261. 

form  of  thorax  in,  137. 

large  joints  in  cases  of,  23. 
Rigidity  of  muscles,  261. 
Ringworm,  183. 
Risus  sardonicus,  27. 
Rupia,  180. 


S. 


Saccharimeter,  215. 
Saliva,  31. 

diminution  of,  31, 

increase  of,  31. 

reaction  of,  31. 
Salivation,  31. 
Sanguine  constitution,  21. 
Santonin,  urine  colored  by,  191. 
Sarcinse  ventriculi,  39. 
Sarcoptes  scabiei,  185. 
Saturnine  paralysis,  250. 
Scabies,  180-185. 
Scales,   180. 
Scapular  reflex,  252, 
Scarlet  fever,  desqumation  of,  180. 

throat  in,  32. 

tongue  in,  30. 
Scars,  180. 
Sciatica,  234. 

Scleroderma,  fissures  of,  i8l. 
Scorbutus,  see  scurvy. 
Scotoma,  239. 

Scurvy,  spongy  gums  in,  28. 
Second  sound  of  heart,  86. 


INDEX. 


281 


Sediments,  urinary,  219. 

of  acid  urine,  222. 

of  alkaline  urine,  224. 

table  of  inorganic,  222. 
Semicircular    canals,    disease    of, 

253- 
Senna,  urine  colored  by,  191. 
Sensation,    common    or    general, 
236. 
of  pressure,  236. 
of  locality,  237. 
of  temperature,  237. 

tactile,  236. 
Sensations,  perverted,  235. 

subjective,  234, 
Sense  of  hearing,  244. 
of  sight,  238. 
of  smell,  246. 
of  taste,  245. 
Sensibility,     common     cutaneous, 

236. 
Sensory  functions,  nervous  system, 

233- 
Serum-globulin  in  urine,  209, 

clinical  significance  of,  211. 
Sexual  function,  248. 
Shrinking  of  thorax,  137-144. 
Sight,  sense  of,  238. 
Sixth  nerv^e,  paralysis  of,  241. 

spasm  of,  242. 
Skin,  blueness  of,  18. 
bronzing  of,  19, 
elements   of,   involved  in  the 

eruption,  178. 
eruptions,  177. 
grayness  of,  20. 
pitting  of,  20. 
trophic  affections  of,  256. 
Skull,  condition  of,  260. 
Sleep,  259. 

Small-pox,  eruption  of,  180. 
pitting  of  skin  after,  23. 
swelling  of  tongue  in,  29. 
temperature  of,  24. 
Smell,  sense  of,  246. 
Solids  of  urine,  193. 
Somnambulism,  259. 
Somnolence,  259. 
Sordes  on  lips,  26. 
Sore  .throat,  32. 
Sound,  uterine,  264. 
Sounds,  adventitious,  accompany- 
ing respiration,  170. 
in  arteries,  98. 


Sounds  of  the  heart,  83. 

enfeeblement  of,  86. 
impurity  of,  86. 
intensification  of,  86. 
modifications  of,  85. 
reduplication  of,  86. 
Spasm  of  ocular  nerves,  241. 
of  sixth  nerve,  242. 
of  third  nerve,  241. 
of  voluntary  muscles,  250. 
Specific  gravity  of  urine,  192. 
Speculum,  nasal,  128. 

vaginal,  233. 
Speech,  affections  of,  258. 
Spermatozoa  in  urine,  221. 
Sphygmograph,  104,  iii. 
Sphygmographic  tracing,   healthy, 

105. 
Sphygmomanometer,  116. 
Spinal    cord,    cilio-spinal    region, 
242. 
paralysis,  electricity  in,  249. 
Spine,  condition  of,  260. 
curvature  of,  260. 
percussion  of,  260. 
Spirochaete  Obermeierii,  66. 
Spirometer,  145. 
Spleen,  consistence  of,  50. 

displacements  of,  58. 
enlargement  of,  50-58. 
palpation  of,  49. 
percussion  of,  57. 
position  of  in  abdomen,  57. 
tumors  of,  45, 
Splenic  fever,  65. 
Sponge  tents,  234, 
test,  hot,  260. 
Spongy  gums  in  scurvy,  28. 
Sputa,  121. 

bronchial  casts  in,  126. 
Charcot's  crystals  in,  127. 
chemical  characters  of,  122. 
epithelial  cells  in,  125. 
lung  tissue  in,  126. 
micro-organisms  in,  127. 
microscopic     examination    of, 

124. 
physical  characters  of,  123. 
tubercule-bacillus  in,  127. 
varieties  of,  122. 
Squamae,  180. 
Squint,  240. 

Stellar  phosphate  in  urine,  224. 
Stenosis  of  larynx,  146,  147. 


282 


INDEX. 


Stenosis,  of  trachea,  146,  147. 
Stethograph,  145. 
Stethoscope,  83,  163. 
Stomach,  examination  of,  44. 

palpation  of,  50. 

percussion  of,  59. 

position  of,  59. 

tumor  of,  45,  51. 
Stomatitis,  28. 
Stone  in  bladder,  pain  caused  by, 

188. 
Strabismus,  240. 
"  Strawberry  tongue,"  30. 
Strychnine-poisoning,  risus  sardon- 

icus  in,  27. 
Strumous  constitution,  22. 
Subcutaneous  emphysema,  20. 

oedema,  20. 
Subjective  sensations,  234. 
Succussion,  hippocratic,  176. 
Sugar  in  urine,  estimation  by  Pa- 
vy's  method,  214. 

by  circular  polarization,    215. 

tests  for,  214. 
Sulphates  in  urine,  detection  and 
estimation  of,  203. 

quantity  excreted,  204. 
Sulphocyanic  acid  in  urine,  204. 
Sulphur  in  urine,  205. 
Sulphuretted    hydrogen    in   urine, 

205. 
Superficial  reflexes,  252. 
Superior  laryngeal  nerve,  paralysis 

of,  133- 
Supra-renal   capsules,    disease    of, 

causing  bronzing,  19, 
Swallowing,  247. 
Sweat,  critical,  20, 
Swelling  of  ankles,  20. 
Sycosis  menti,  180,  183. 
Sympathetic  resonance,  theory  of, 

150. 
Syncope,  70. 
Syphilides,  178,  179. 
Syphilis,  62. 

crusts,  180. 

fissures  of,  26,  180. 

hereditary,  16. 

ocular  paralysis  in,  241. 

pallor  of,  23. 

signs  of  former,  23. 

teeth  in,  27. 

tongue  in,  30, 
Systolic  heart-sound,  83,  84. 


Systolic,     indrawing    of     thoracic 
wall,  72. 
murmur,  aortic,  93. 
mitral,  90. 
pulmonary,  93. 
tricuspid,  92. 
vesicular  breathing,  165. 


T. 


Taches  c6r6brales,  254. 
Tactile  sensation,  236. 
Taenia  mediocanellata,  42. 

solium  42, 
Tangle  tents,  235. 
Tape-measure,  143. 
Taste,  sense  of,  245. 
Taurin  in  urine,  204. 
Teeth,  27. 
Temperament,  21. 
Temperature,  23. 

sensibility  to,  237. 
Tenesmus,  40. 

Tension   of  chest  wall  influencing 
percussion,  155. 

pulmonic     tissue     influencing 
percussion,  155. 
Tents,  235. 
Test  types,  239. 

Tests  for  albumen  in  urine,  207. 
Tetanus,  risus  sardonicus  in,  27. 
Theory  of  percussion,  147. 
Thermo-ansesthesia,  237. 

-hyperaesthesia,  237.  * 

Thermometer,  23. 
Third  nerve,  paralysis  of,  240. 

spasm  of,  241. 
Thirst,  36. 
Thoracic  duct,  61. 
Thoracic   wall,  modifying   percus- 
sion, 154, 

fluctuation  in,  143. 

tension  of,  influencing  percus- 
sion, 155. 
Thoracometer,   145. 
Thorax,  antero-posterior  diameter, 

144. 
Thorax,  circumference  of,  143,  144. 

enlargement  of,  137,  144. 

form  of,  137,  141. 

heteromorphisms  of,  137. 

measurement    of    movements 
of,  145. 

movements  of,  141. 


Index. 


^83 


thorax,  regions  of,  135. 

respiratory  movements  of,  138. 

shrinking  of,  137,  144. 

vibrations  of  wall  of,  148. 
Throat,  sore,  32. 
Thrombosis,  loi. 
Thrills,  endocardial,  78. 
Thrush,  28,  31. 
Thymus  gland,  64. 
Thyroid  gland,  63. 
Tic  douloureux,  234. 
Tight-lacing,  effect  of,  on  liver,  49. 
Tinea  circinata,  183. 

favosa,  182. 

sycosis,  180,  183. 

tonsurans,  183. 
Tinkling,  metallic,   172. 
Tongue,  28. 

form  of,  28. 

fur  on,  30. 

movements  of,  29. 

surface  of,  29. 
Tonic  spasm  of  voluntary  muscles, 

250. 
Tonsillitis,  32, 
Topographical  percussion,  161. 

theory  of,  156. 
Tracings,  cardiographic,  in  health, 
112. 

measurement  of,  note  on,  117. 

sphygmographic,      in     health, 
105. 
Tracheal  note  of  Williams,  159. 
Transparency  of  urine,  192. 
Traumatic  paralysis,  electric  con- 
ditions of,  249. 
Tremor,  251. 

Trichocephalus  dispar,  207. 
Trichophyton,  183. 
Tricuspid  area,  84. 

incompetence,  92. 

jugular  pulsation  in,  73. 

praesystolic  murmurs,  92. 

stenosis,  92. 

systolic  murmurs,  93. 

valve,  83. 
Triple  phosphate  in  urine,  224. 
Trochlearis,    nervus,    paralysis  of, 

241. 
Trophic  functions,  255. 
Tube-casts  in  urine,  220. 

epithelial,  220. 

fatty,  220, 

granular/ 221,     / 


Tube-casts  in  hyaline,  221. 

pus,  221. 

waxy,  252, 
Tubercular  meningitis  causing  re- 
traction of  abdomen,   44. 

peritonitis  causing  ascites,  54. 
Tubercule-bacillus  in  sputa,  127. 
Tubercules,  179. 
Tubular    respiratory   murmur,    see 

bronchial. 
Tumefaction  of  larynx,  132. 
Tumors,  cerebral,  ophthalmoscopic 
appearances  in,  244.  • 

faecal,  51. 

of  abdomen,  45. 

of  kidneys,  45,  52. 

of  liver,  45,  48. 

of  mesenteric  glands,  51. 

of  omentum,  45,  51. 

of  ovaries,  45,  52. 

of  pancreas,  50. 

of  skin,  179. 

of  spleen,  45,  49. 

of  stomach,  44,  50. 
Tuning-fork  test,  244. 
Tupelo  tents,  235. 
Twitching,  muscular,  251,  261. 
Tympanitic  percussion,  156. 
Types,  test,  239. 

Typhoid  state,   expression  in,  21. 
Typhus  fever,  temperature  of,  25. 

urea  increased  in,  198. 
Tyrosin  in  urine,  224. 

U. 

Ulceration  of  larynx,  132. 

Ulcers,  181. 

Umbilicus,  distension  of  veins  at, 

44- 
Uraemia,  convulsions  of,  251. 

diarrhoea  caused  by,  40. 

respiration  in,  140. 

urea  in  perspiration  of,  46. 
Urate  of  ammonium  in  urine,  226. 
Urates   as   an  amorphous  deposit 

in  urine,  222. 
Urea,  estimation  of,  195, 

quantity  excreted,  199. 

in  perspiration,  20. 
Urethritis,  pain  of,  188. 

pus  in  urine  in,  219. 
Uric  acid  as  a  urinary  deposit,  223, 

detection  of,  199. 


284 


INDEX. 


Uric  aeid,  estimation  of,  199. 
in  urine,  199. 
quantity    excreted    in    health, 

199. 
Urinary  system,  188-226. 
Urine,  abnormal   constituents   of, 

206. 
acid,  sediments  found  in,  222. 
acidity  of,   194. 
albumen  in,  206. 
alkaline,  sediments  of,  224. 
alkalinity  of,  194. 
ammoniacal,  194. 
ammonio  -  magnesian      phos- 
phate in,  224. 
amorphous  phosphate  of  lime 

in,  224. 
bile  acids  in,  218. 

pigment  in,  218. 
blood  in,  217. 

corpuscles  in,  219. 
carbonate  of  lime  in,  226. 
chlorides  in,  202. 
cholesterin  as  a  deposit  in,  224. 
chylous,  62. 
color  of,  189. 
creatinin  in,  200. 
crystallized  phosphate  of  lime 

in,  224. 
cystin  as  a  deposit  in,  224. 
epithelium  in,  220. 
examination  of,  189. 
fermentation  of,  194. 
fibrin  in,  210. 
indican  in,  201. 
leucin  and  tyrosin  as  deposits 

in,  224. 
melanin  in,  191. 
micro-organisms  in,  221. 
mucous  cloud  in,  192. 
mucus  in,  212. 
normal  constituents  of,   195. 
organic  deposits,  219. 
oxalate  of   lime    as   a   deposit 

in,  223. 
para-globulin  in,  209. 
pepton  in,  211. 
phosphate   of   magnesium   in, 

225. 
phosphates  in,  204. 
pigments  of,  190. 
propepton  in,  209. 
purpurin  in,  191. 
pus  corpuscles  in,  219. 


Urine — continued. 

quantity  of,  189. 

reaction  of,  194. 

serum-globulin  in,  209. 

solids  of,  193. 

specific  gravity  of,  192. 

spermatozoa  in,  221. 

stellar  phosphate  in,  224. 

sugar  in,  212. 

sulphates  in,  203. 

transparency  of,  192. 

triple-phosphate  in,  224. 

tube  casts  in,  220. 

urate  of  ammonium  in,  225. 

urates  as  a  deposit  in,  223. 

urea  in,  195. 

uric  acid  as  a  deposit  in,  223. 

uric  acid  in,  199. 

uro-bilin  in,  190. 

uro-erythrin  in,  191. 
Urinometer,   192. 
Uro  bilin,  190. 
Uro-erythrin,  191,  222. 
Uroxanthin  in  urine,  201. 
Urticaria,  179. 

Uterine  canal,  occlusion  of,  leading 
to  amenorrhoea,  227. 

disease,  causing  vomiting,  38. 

sound,  234. 

tents,  235. 
Uterus,  dilatation  of  canal  of,  235. 

diseases  of,  leading  to  menor- 
rhagia,  227. 

to  dysmenorrhoea,  228. 

displacements  of,  235. 

rudimentary,  leading  to  amen- 
orrhoea, 227. 

V. 

Vagina,    occlusion   of,    leading  to 

amenorrhoea,  227. 
Vaginal  examination,  232. 

speculum,  233. 
Valves  of  the  heart,  83. 
Vaso-motor  affections,  cutaneous^ 

254- 

visceral,  255. 
functions,  254. 
Veins,  100. 

auscultation  of,  loi. 
bruit  de  diable  in,  loi. 
cervical,  loi. 
inspection,  100. 


INDEX. 


285 


Veins,  overfilling  of,  loi. 

pulsation  of,  72. 

undulation  of,  loi. 
Vegetable  parasites  of  skin,  182. 
Venous  humming  murmur,  loi. 

pulse,  70. 
Vertigo,  235. 

labyrinthine,  253. 
Vesical   calculus,   pain    caused    by, 

188. 
Vesicles  in  skin.  179. 
Vesicular  breathing,  164. 
Vessels,  lymphatic,  61. 
Vibrations  of  air  in  lungs,  148. 

of  pleximeter,  148. 

of  thoracic  wall,  148. 
Visceral  motor  functions,  247. 

neuralgia,  234. 

sensations.  236. 

trophic  affections,  256. 

vaso-motor  affections,  255. 
Vision,  alterations  in  extent  of  field 
of,  239. 

alterations    in    perception    of 
colors,  240. 

diminution    of    acuteness    of, 

239- 
Vital  capacity,  145. 
Vocal  cords,  cadaveric  position  of, 

133- 
paralysis  of,  129,  132. 


Vocal  cords,  fremitus,  142. 

resonance,  174. 
Voice,  auscultation  of,  174. 

huskiness  of,  in   laryngeal  af- 
fections, 129,  133. 
Voluntary    muscles,    functions   of, 
248. 

reflex  movements  of,  251. 

spasm  of,  250. 
Vomicae,  pulmonary,  amphoric  re- 
sonance in,  160. 

amphoric  respiration  over,  168. 

bronchial  breathing  over,   168. 

cracked-pot  sound  in,  159. 

metallic  tinkling  in,  172. 

percussion  of,  158. 

vocal  resonance  over,  175. 
Vomited  matter,  39. 
Vomiting,  causes  of,  38. 
Vulva,  examination  of,  229. 

W. 

Water-brash,  38. 
Weight,  17, 
Wheals,    179. 
Whooping-cough,  121. 
Williams'  tracheal  note,  159. 

Y. 

Yellow  fever,  vomiting  of  blood  in' 
39. 


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